Fillable Short-Term Disability Claim Form printable pdf download

A Guide for Successfully Completing the

Group Short-Term Disability Claim Form

Mutual of Omaha appreciates the opportunity to provide you with valuable income protection. We rely on the

information you provide on this form to effectively determine if you qualify for group short-term disability benefits.

This guide provides information and instruction to help you successfully complete and submit the claim form. Please

consult your employer/benefits administrator if you need assistance in providing information for the form.

Important Tips for Paper Copy Submission

Authorization to Disclose Personal Information &

Authorization to Disclose Health Information

Prior to submission, make sure you have provided

to my Employer

all required information and answered all questions

Both authorizations are to be completed by the Employee.

completely and accurately. If information is missing or

Dates should include the month, date and year. In order to be

cannot be read, the processing of your form will be delayed.

considered complete, the form must be signed by you or your

The following guidelines provide valuable information to

legal representative.

help you successfully complete the form.

By signing the authorization, you are applying for short-

Please make a copy of the completed form for your records

term disability benefits with Mutual of Omaha/United of

before submitting it to Mutual of Omaha/United of Omaha.

Omaha and are agreeing to allow disclosure of personal

information to the necessary parties for the purpose of

Section 1: Employee Statement

claim processing.

This section is to be completed by the Employee. Dates

If the name associated with any of your medical records

should include the month, date and year. In order to be

differs from the name provided on the form, provide any

considered complete, the form must be signed by you.

alternate names. This might occur in the event of a name

Group ID Number for your Employer will consist of eight

change due to marriage or adoption.

characters, beginning with “G000” and followed by four

Guidelines for Section 2: Employer’s Statement

additional letters or numbers specific to your Employer.

This section is to be completed by the Employer. Dates should

Job Title is the title of your position held with the Employer.

include the month, date and year. In order to be considered

The Hours Worked per Week is the number of hours you

complete, the form must be signed by the Employer.

worked per week for the Employer.

Group ID Number consists of eight characters, beginning

Height should be provided in feet and inches.

with “G000” and followed by four additional letters or

numbers.

Weight should be provided in pounds.

Date Covered Under This Plan indicates the date in which

Dominant Hand indicates whether you are primarily right-

the Employee’s coverage became effective.

or left-handed.

If the Employee is eligible for salary continuation/sick

Date of Disability is the first day you were absent from work

leave, this does not include Mutual of Omaha/United of

because of the disabling condition.

Omaha short-term disability benefits, paid time off or

Date First Treated is the date you first sought medical care

vacation compensation.

because of the disabling condition.

Guidelines for Section 3: Attending Physician’s

Other Income means money you are currently receiving

Statement

or have applied to receive from any source in addition to

your claim for disability benefits with Mutual of Omaha/

This section is to be completed by the Attending Physician.

United of Omaha.

Dates should include the month, date and year. In order to

be considered complete, the form must be signed by the

Attending Physician.

Required Fraud Warnings

Before completing the claim form, please read the Required

Fraud Warnings listed on the following page.

MUG6110A_0114

STD Claim Form Guide_1009

Short-Term Disability Claim Form

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