Form Abj10368g-3 - Group Voluntary Std / Ltd / Waiver Of Premium Claim - 2013 Page 3
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6EMPLOYER’S STATEMENT
Remember, it is a crime to fill out this form with facts you know are false or to leave out facts you know are relevant and important. Check to
be sure that all information is correct before signing. Please refer to page 2 for notices specific to your state.
1.
I hereby certify that
did not perform any part of his/her work from,
through,
2.
Did insured work light duty or part-time?
Yes
No
If yes, give dates
3.
Prior to inability to work, he/she worked
hours per week and is considered
exempt or
non-exempt.
4.
When recovered, will he/she resume work?
Yes
No
If not why?
5.
Is this a Workers’ Compensation case?
Yes
No Date Workers’ Compensation benefits began
/
/
MO/DAY/YR
Name of Workers’ Compensation Company
6.
Section 125: Were the premiums for our disability income policy paid with pre-tax dollars under a Section 125 Plan?
Yes
No
7.
Is the employee receiving or has he/she received continued pay?
Yes
No
If yes, please complete the following:
Pay Period
Amount
Source of Income
From
To
8.
Current Salary or Hourly Rate:
9.
Name of Employer:
Date:
/
/
MO/DAY/YR
Address:
By:
Official Position:
Telephone number: (
)
10. The employee’s job title or position is:
11. Is the employee covered under any other disability policy through the company?
12. Has employee returned to work?
Yes
No
If yes, give date:
/
/
MO/DAY/YR
Remarks:
ABJ10368G-3
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