Short Term Disability Claim Statement printable pdf download

Voluntary Short Term Disability

Companion Life Insurance Company

Post Office Box 100102

Employee Enrollment Form

Columbia, South Carolina 29202-3102

800-753-0404

To bE complETED by EmployEr

Name of Employer (Use Name from Group Billing Notice or Master Application)

Group Number

To bE complETED by EmployEE

Your Name

Last

First

Middle Initial

Date of Birth

Social Security Number

Date Employed Full-Time

Coverage Effective Date

Occupation

Annual Earnings

Hours Worked Per Week

Sex

Beneficiary

Relationship

bENEFiT lEVElS

Select the Benefit Level (A-W) that meets your needs from the chart below and enter the Benefit Level letter in the box on the right.

Benefit

Weekly

Your Annual Salary

Benefit

Weekly

Your Annual Salary

Level

Benefit

Must Be at Least

Level

Benefit

Must Be at Least

$150

$11,700

$750

$58,500

benefit level Selected

$200

$15,600

$800

$62,400

$250

$19,500

$850

$66,300

$300

$23,400

$900

$70,200

$350

$27,300

$950

$74,100

$400

$31,200

$1,000

$78,000

$450

$35,100

$1,050

$81,900

$500

$39,000

$1,100

$85,800

Weekly benefits will Equal the

$550

$42,900

$1,150

$89,700

Amount Selected, Not to Exceed

$600

$46,800

$1,200

$93,600

% of basic Weekly Earnings

$650

$50,700

$1,250

$97,500

$700

$54,600

I elect the above benefits which I have selected from all those for which I am eligible. If any contribution from me is necessary to pay part of the cost of

the insurance, I authorize my employer to deduct the necessary contribution from my wages.

FrAuD WArNiNg (Not Applicable in AZ, Fl, mD, VA or mN): Any person who knowingly and with intent to defraud any insurance company or

other person files an application for insurance or a statement of claim containing any materially false information or conceals for the purpose of

misleading, information concerning any fact material thereto commits (in TX, may be committing) a fraudulent insurance act, which is a crime and

subjects (in KS, which may be determined by a court of law to be a crime which subjects) such person to criminal and civil penalties.

FrAuD WArNiNg (Fl only): Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an

Do Not Write in This

Date

Your Signature

Box Unless Instructed

To Do So

If you are refusing coverage, sign below and return this form to your employer.

I acknowledge that I have been offered Voluntary Short Term Disability Insurance by my employer. I hereby wish to waive my right to be insured under

this plan. I am aware that I must furnish evidence of insurability satisfactory to Companion Life Insurance Company, at my own expense, if I should

apply at a later date. The company shall have the right to decline coverage.

Date:

Signature:

95982

Rev. 9/12

Short Term Disability Claim Statement

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