Short Term Disability Claim Form Page 3
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3UFCW Local 1459 and Contributing Employers Health & Welfare Fund
33 Eastland Street - Springfield, MA 01109-2348
Phone: 413.733.0177 Toll Free: 1.800.634.2700 Fax: 413.733.3325
To Qualify for Weekly Disability Income Benefits (Short Term Disability), you must:
1) Be under the direct care of - and regularly attended by - a legally licensed physician or
covered provider;
2) Be eligible for benefits at the time of the disability;
3) Be totally and continuously disabled and prevented from performing any or all duties of your
employment;
4) Not be engaged in any other occupation for wage or profit during the disability period;
5) Not receiving compensation for lost wages from automobile insurance or Workers’
Compensation Law,
6) Not be disabled due to an illness or injury for which one or more third parties are or may be
legally liable.
Miscellaneous Information
You Physician must include an approximate date of return to work when completing the
original disability form.
If your return to work date changes at any time during your disability, you must send in a
new Physician note with that date as soon as possible. Call the Fund office at 413-
733-0177 or Toll Free at 800-634-2700 the day you return to work if it is before the date
your physician released you.
Weekly Disability Income Benefits begin on the 1
st
th
day of an accident or the 8
day of an
illness.
One week of disability pay is a period of seven days, including the weekend. For any
period of disability that is less than one week in duration, the benefits will be paid at one-
seventh of the weekly benefit amount multiplied by the number of days.
Benefits are 66.66% of your weekly basic earnings at the time you become disabled not
to exceed the Maximum Benefit or Duration for your Benefit Plan:
Benefit Plan
Maximum Benefit
Maximum Duration
A
$375 per week
13 Weeks
B
$100 per week
13 Weeks
C
$420 per week
26 Weeks
D
$135 per week
26 Weeks
Your disability benefits will be processed on Wednesday of each week and will include
benefits through Tuesday of the same week. This will continue until this benefit is
exhausted or you have failed to meet the requirements for disability benefits.
If disability is due to maternity, the maximum time allowed is 6 weeks after normal
delivery or 8 weeks after a Cesarean delivery. If you are disabled prior to your date of
delivery, the benefit will not exceed the Maximum Duration for your Benefit Plan.
This summary is for illustrative purposes only and is not a legal document. The plan booklet, contract, and/or
Summary Plan Descriptions both now and in the future are legal documents you should rely on for specific
information.
Printed at UFCW Local 1459 Health & Welfare Fund Office 01-13
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