Preliminary Statement Of Disability-Std Form

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NAVAJO NATION EMPLOYEE BENEFIT PLAN
P.O. Box 2069
P.O. Box 2069
PRELIMINARY STATEMENT OF DISABILITY-STD
Cottonwood, AZ 86326
Plan Number 710000
THIS SECTION TO BE COMPLETED BY EMPLOYEE (Please Print)
Full Name (Last, First, M.I.)
Social Security No.
Date of Birth
Mailing Address
Employer
Home Phone (
)
City
State
Zip
Occupation
Gender
Type of Disability
Male
Female
Accident
Illness
Maternity
Describe how and where accident occurred or list symptoms of illness.
Is your injury or illness related to your work?
Date claim filed with Workers' Compensation Program
Yes
No
Complete if your claim is for an accident:
Complete if your claim is for an illness:
Date accident occurred________________________________________
Date symptoms first noticed__________________________________
How and Where? ____________________________________________
Date first treated___________________________________________
Date symptoms first noticed____________________________________
List symptoms of illness_____________________________________
____________________________________________
Date first treated_____________________________________________
If Workers' Compensation denied your claim, attach copies of denial letter, original claim filed, and Employee's Claim Petition
I have been unable to work because
I returned to work Part Time on (m/d/yr)
I returned to work Full Time on (m/d/yr)
of the disablity since (m/d/yr):
Date first treated for illness or injury
Doctor name and address
Hospital name and address
Have you had same or similar
If so, when?
Doctor name and address
Hospital name and address
conditions in the past?
Yes
No
Describe any other income you are receiving or are eligible to receive as a result of your disability: (Examples: Social Security, Workers' Compensation,
State Disability, Pension Disability, etc.)
Describe Source
Amount of Income
Date Income Began
Date Income Ended
If your request for benefits is approved do you want us to withhold
_________________________
amounts from each benefit check for Federal Income Tax purpose?
If "yes", enter amount $_______________
Yes
No
(Amount per week $20.00 minimum)
Signature
AUTHORIZATION TO RELEASE INFORMATION-
Must be signed and dated to validate the claim.
To: Any licensed physician, medical practitioner, hospital, clinic, or other medical related facility, insurance company, employer, or consumer reporting agency.
(1) I authorize you to release the following to HMA, Inc., their reinsurers, or any consumer reporting agency on their behalf for purposes of determining disability
benefits: full information, including copies of records, concerning medical examinations, history and treatment, occupation, income, and financial status.
(2) I have a right to receive a copy of this authorization upon request. A photocopy of this authorization shall be considered as valid as the original.
This authorization shall be valid for a period of one year from the date of signature.
DATE________________
SIGNATURE OF EMPLOYEE____________________________________________________________
THIS SECTION TO BE COMPLETED BY EMPLOYER (Please Print)
Employee's Name
Last Day Worked
Reason for Stopping Work
Date Returned
Date Returned
Full Time
Part Time
Date Hired
Occupation at Time of Disability
Work Schedule at Time of Disability
Basic Annual Earnings as of Last Day
Days/wk:
Hrs/day:
Worked $
By any Employer-Employee, Labor Management, Union Welfare Plan or any State Disability,
Is Employee eligible for Workers' Compensation?
will (or has) Employee file(d) for Unemployment Compensation or for Disability provided?
Amount $
Carrier
Yes
No
If yes, please specify:
Yes
No
Employer Address
Telephone
Title
Date
Signature
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY FILES A STATEMENT OF CLAIM CONTAINING ANY MATERIALLY
FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION,CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT
INSURANCE ACT, WHICH IS A CRIME.

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