Short-Term Disability Claim Form
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1
2Short-Term Disability Claim Form
Mutual of Omaha Insurance Company
United of Omaha Life Insurance Company
S-1 Group Disability Management Services
Mutual of Omaha Plaza
Omaha, NE 68175-0001
800-877-5176
Fax (402) 997-1865
Part I – Employee Statement (ALL QUESTIONS MUST BE ANSWERED TO AVOID DELAY)
Employer Name
Policy Number
Job Title
Hours Worked
per Week
Name
Address
City
State
ZIP
(Area Code) Phone Number
Social Security Number
Date of Birth
Height
Weight
Dominant Hand:
Male
Single
Widowed
■
■
■
Right
Left
Female
Married
Divorced
■
■
■
■
■
Date of Disability (1st Day Absent) (Mo.)/(Day)/(Year)
Date First Treated (Mo.)/(Day)/(Year)
Physician’s Name
Nature of illness and when symptoms first appeared, or describe how and where accident occurred.
Was the disability work related?
Yes
No
Have you filed a Worker’s Compensation Claim?
Yes
No
■
■
■
■
Other income you have filed for, are receiving, or are eligible for:
Amount
Date Claim Filed
Date Benefits Began
Workers’ Compensation
__________________
___________________________
___________________________
State Disability
__________________
___________________________
___________________________
Other
__________________
___________________________
___________________________
Part II – Employer’s Statement (ALL QUESTIONS MUST BE ANSWERED TO AVOID DELAY)
Company Name
Policy Number
Class
Division or Location
Address
Street
City
State
ZIP
Weekly earnings as defined by the Plan:
No. of Hours Scheduled to Work Weekly: _________
(Please note: Benefits will be calculated based on premium received.)
Was disability caused by employment?
Yes
No
Has workers’ compensation claim been filed?
Yes
No
■
■
■
■
Does the employee contribute toward the premium?
Yes
No If yes, what percent is paid by the employee? ______ % Pre-tax ______ Post-tax ______?
■
■
Is this employee eligible for salary continuation/sick leave?
Yes
No
If yes, what is the weekly amount? $____________
■
■
When do benefits begin? __________________ End __________________
Date of Hire (Mo.)/(Day)/(Year)
Date Covered Under This Plan
Is employee covered for long-term disability by a Mutual of Omaha/United of Omaha policy?
Yes
No
■
■
Is employee covered for Group Life by a United of Omaha policy?
Yes
No If yes, and it would appear your employee’s disability will last longer than
■
■
6 months, please answer the following questions: Effective Date of Life Insurance _____________ Annual Salary _____________
Date Insurance Terminated or if not Terminated, “paid to” date ____________ Master Policy Number _____________ Insurance Class _____________
Amount of Insurance on the last day worked _____________
Please contact employee’s direct supervisor and then circle the strength demand below which best describes the employee’s job:
S - Sedentary
10 Lbs. Maximum lifting, occasional lift/carry of small articles. Some occasional walking or standing may be required.
L - Light
20 Lbs. Maximum lifting with frequent lift/carry up to 10 Lbs. A job is light if less lifting is involved but
significant walking/standing is done or if done mostly sitting but requires push/pull on arm or leg controls.
Circle
M - Medium
50 Lbs. Maximum lifting with frequent lift/carry up to 25 Lbs.
One
H - Heavy
100 Lbs. Maximum lifting with frequent lift/carry up to 50 Lbs.
V - Very Heavy
Over 100 Lbs. Lifting with frequent lift/carry over 50 Lbs.
Employee’s Job Title
Last Day at Work (Mo.)/(Day)/(Year) On that day, did the employee work a full day?
Yes
No If no, how many hours were worked?
■
■
Description of major job duties – please attach Job
Has the employee returned to work?
Yes
No
If yes, when?
■
■
description
Signature/Title
Date
(Area Code) Phone Number
(Area Code) Fax Number
Please notify us if the employee returns to work after the submission of this form.
MUG6110_0407
MUG6874_STD_0906
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