Short Term Disability Claim Form Initial Assessment

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PLAN ADMINISTRATOR
c/o COUGHLIN & ASSOCIATES LTD.
P.O. Box 764, Winnipeg, Manitoba R3C 2L4
Phone (204) 942-4438
Toll Free 1-888-204-1234
coughlin
TM
SHORT TERM DISABILITY CLAIM FORM – INITIAL ASSESSMENT
employee benefits specialists
Part 1 - CLAIMANT’S STATEMENT
Ask your doctor to complete the Attending Physician’s Statement on the reverse side. When both sides of the form are completed and signed,
send the completed form to the Plan Administrator’s Office at the address listed above for processing.
SECTION A: GENERAL INFORMATION
Mr.
Mrs.
Ms.
Sex:
Male
Female
Date of Birth _______
______________
Day
Month
Year
__________________________
___________________________
Surname
Given Name
Social Insurance Number
__________________________________________________________________________________________________________________
Street Address
City
Province
Postal Code
Telephone Number
____________________
________________________
__________________________
____________________
Group Plan Name
Occupation
Name of Employer
Employer’s Phone Number
SECTION B: CLAIM INFORMATION
Was the reason you stopped working due to:
Illness
Injury away from work
Motor Vehicle Accident
Occupational Illness or Work Accident
(not while working)
If you have suffered an injury, please describe how, when, and where the injury occurred. ________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
What was the last day you worked? _____________________
Were you performing:
Regular Duties
Modified Duties
Day
Month
Year
What was the date you were first unable to work?
________
_____________
Day
Month
Year
Please describe all your symptoms, including frequency and severity. _________________________________________________________
__________________________________________________________________________________________________________________
When did you first notice these symptoms?
_____________________
Day
Month
Year
When were you first treated by a physician?
_____________________
Day
Month
Year
Have you ever had the same or similar illness or injury?
Yes
No
If yes, please provide dates and name(s) of Physicians who treated you at that time. ______________________________________________
__________________________________________________________________________________________________________________
Please describe the major duties of your occupation. ______________________________________________________________________
__________________________________________________________________________________________________________________
Please describe why you are unable to perform the duties of your occupation. ___________________________________________________
__________________________________________________________________________________________________________________
Do you have an expected date of return to work?
Yes
No
If yes, please provide date: _______
______________
Day
Month
Year
SECTION C: OTHER INCOME INFORMATION
If you have applied for, or are receiving any income from any of the following sources, please complete the following and submit proof of
payments, if applicable.
Source
Claim #, Contact Name, & Telephone No.
Have you applied?
Are you receiving payment?
Monthly
Yes
No
Yes
No
Pending
Amount
Worker’s Compensation
Employment Insurance
Auto Insurance
Other Insurer
SECTION D: EMPLOYEE AUTHORIZATION AND DECLARATION
I permit any physician, dentist or other authorized person or organization in possession of my personal records to provide Coughlin & Associates Ltd.
with any information necessary, including hospital records and clinical notes, to administer my claim. I authorize Coughlin the use of my Social
Insurance Number for the purposes of government reporting, identification and administration of my group benefits; Coughlin to exchange my personal
information with the following person, organizations or parties: Health care providers; financial institutions; government agencies; insurance companies;
employers or former employers; my local union or plan trustees and auditors; and Coughlin to use the personal information on file to provide me with
additional information regarding any benefits to which I am entitled. I agree that a photocopy or electronic copy of this Authorizations and Declarations
section is as valid as the original.
I understand that the information contained in this form, once completed and submitted to Coughlin & Associates Ltd., will be used in the administration
of my claim as well as for statistical analysis.
I certify that the information contained in this form is true and complete to the best of my knowledge.
_____________________________________________________
________________________________________________________
Signature
Date
Protecting your personal information: The administrator of your group benefit plans is Coughlin & Associates Ltd. At Coughlin, we recognize and
respect every individual’s right to privacy. When personal information is provided to us, we establish a confidential file that is kept in the offices of
Coughlin, or the offices of any organization authorized by Coughlin. We use the information to administer the group benefits plan. We limit access to
information in your file to Coughlin staff or persons authorized by Coughlin who require it to perform their duties, to persons to whom you have granted
access, and to persons authorized by law.

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