Form Abj10368g-3 - Group Voluntary Std / Ltd / Waiver Of Premium Claim

Form Abj10368g-3 - Group Voluntary Std / Ltd / Waiver Of Premium Claim - 2013 Page 2

DISABILITY AND WAIVER OF PREMIUM CLAIMS (CERTIFICATEHOLDER)

INJURY OR ILLNESS YOU ARE CLAIMING:

Date you were first treated for your illness or injury:

Date you were last treated for your illness or injury:

MO/DAY/YR

Date of your accident or the date you first noticed the symptoms of your illness:

MO/DAY/YR

If you are claiming an injury, did your injury occur at work?

Yes

List all physicians seen in the past five (5) years:

Name

Address

Phone

Specialty

Dates Consulted

Reason for Consult

List all hospital confinements in the past five (5) years:

Name

Address

From/To

Reason Confined

List all pharmacies used in the past five (5) years: (include address and phone number)

I have been unable to work since:

I returned to work on a

part-time

full-time basis:

MO/DAY/YR

Describe why you are unable to work:

Are you receiving Disability Benefits (Salary Continuation, Sick Pay, Social Security Disability Income, or Workers’ Compensation) from any other

source? If “yes,” from whom?

DISABILITY CLAIM FOR ROUTINE PREGNANCY

Expected Recovery Period is 6 weeks for vaginal delivery, or 8 weeks for C-Section.

If disabled due to complications of pregnancy, before or after delivery, please complete Policyholder, Attending Physician’s Statement, and

Employer’s Statement sections.

Date of Delivery:

First Date of Treatment:

Type of delivery:

Vaginal

C-Section

MO/DAY/YR

Date of Hospital Confinement:

Name of Hospital:

Phone No.: (

)

MO/DAY/YR

Physician’s Name:

Phone: (

)

Address:

Fax:

(

)

Treating Physician’s Signature:

Date:

Tax Identification No.:

MO/DAY/YR

Referring Physician:

Phone No.: (

)

Mailing Address:

ABJ10368G-3

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Form Abj10368g-3 - Group Voluntary Std / Ltd / Waiver Of Premium Claim - 2013 Page 2

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