Short Term Disability Claim Statement Template
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1
2SHORT TERM DISABILITY CLAIM STATEMENT
Send Completed Form to:
Associated Mutual Hospital Service of Michigan
5800 Foremost Drive • Suite 207 • Grand Rapids, MI 49546 Fax (616) 808-2899
PART 1 - To be completed by the Claimant (please print or type).
Name
Social Security Number
Date of Birth
Street Address
City
State
Zip Code
Home Phone
Male
Sex:
Type of Disability:
E-mail Address
Female
Accident Illness Pregnancy
Describe how and where accident occurred or list symptoms of illness and diagnosis:
Are you receiving or eligible to receive (Check all applicable boxes and describe):
Social Security Social Security disability benefits Workers' Compensation Pension benefits
Yes
No
Is your accident or illness work related?
If "Yes", please explain.
Date symptoms first appeared
Date first treated
Date first unable to work
Physician(s) name and address
I understand and acknowledge that any provider of medical services, insurance company, consumer reporting agency, Social Security Administration,
governmental agency, educational institution, law enforcement agency or employer having medical information with respect to any physical or mental condition,
rehabilitation and other non-medical information or me may give Associated Mutual, or its representatives, any and all such information. I understand Associated
Mutual may discuss my limitations/restrictions with current or prospective employers as they relate to accommodations and possible return to work. I
UNDERSTAND the information obtained by use of this acknowledgement will be used by Associated Mutual to determine the eligibility for benefits. I know that a
photographic copy of this acknowledgement shall be as valid as the original. I agree this acknowledgement shall be valid for the duration of the claim.
If I receive a disability benefit greater than that which I should have been paid, I understand the insurance company has the right to recover such overpayments
from me, including the rights to reduce or adjust future benefits, if any.
Signature
Date
PART 2 - To be completed by the Employer.
Claimant's Name
Date Employed
Effective date of plan
Has claimant made prior claim for benefits?
Yes
No
When?
/
/
Date last worked ____/____/____
Work schedule at time of disability
Occupations, title, or position
Number of hours worked that day ____
____days/week ____hours/day
Describe the claimant's job duties. If available, attach a formal job description.
Basic weekly earnings as of last day worked
Weekly benefit amount
Is claimant eligible for Workers' Compensation as a result
Yes
No
Currently disputed
$
$
of this disability?
Percentage of premium paid by:
Claimant_________%
Employer_________%
Are claimant premium contributions made under Section 125 of the Internal Revenue Code (i.e. a Cafeteria Plan paid with pre-tax dollars?)
Yes
No
Yes
Has claimant returned to work?
Employee's Contract Year:
Available Sick
Remarks:
No
& Vacation Days
If "Yes", on what date ____/____/____
With restrictions
Full capacity
School Year
Twelve Month
Employer's Name
Address
Telephone Number
Fax Number
E-mail Address
Your Name and Title
Date
Signature
Underwritten By: Associated Mutual Hospital Service of Michigan • 5800 Foremost Drive • Suite 207 • Grand Rapids, MI 49546
FORM-AMSTDC0907a
Short Term Disability Claim Statement
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