Disability Claim Form - Principal Financial Group
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7Disability Claim Form
Account number: 1023296
Administered by
Principal Life Insurance Company
Attn: Group Life and Disability Claims Department
Des Moines, Iowa 50392-0002
Employer Statement
Instructions
Please mail, FAX, or email this completed form to: Principal Life Insurance Company, Group Life & Disability Claims Department, Des Moines, IA 50392,
1-800-255-6609, . Please call 1-800-245-1522 with questions on how to complete this form.
1.
This form should be completed in its entirety by the employer, the employee/claimant and attending physician.
2.
If you have any additional information you feel would help in the review of this claim, please attach to this form.
3.
The authorization to release medical information (Page 7) must be completed for all claims and returned with the other sections.
Type and amount of coverage employee is enrolled for with Principal Life Insurance Company.
Life coverage during disability $
Short term disability $
Long term disability $
Employee’s name
I.D. number
Employee’s address
Phone number
Employee’s job title
Date in job
Please complete the job description questionnaire on page 2 and send a copy of your employee’s job description with this completed form.
Employee hours worked per week
Date of employment
Date employee last
Effective date of employee’s coverage
worked
# of hours worked on date last worked
Percentage of premium paid by employer*
% If less than 100%, were premiums paid with employee’s pre-tax dollars?
post tax?
*See Internal Revenue code Section 105(a) and Regulations thereunder.
Reason stopped working
illness
injury
other
Was coverage in force when disability began?
yes
no
Has employee returned to work?
yes
no If yes, give date returned
Number of hours
Is disability due to employment?
yes
no If yes, date filed for Worker’s Compensation
If approved, amount of compensation received $
(If Worker’s Compensation approved or denied, please attach a copy of the award or denial letter with this claim.)
Name and address of Worker’s Compensation carrier (if disability is work related):
Employee’s salary
$
Salary eff date
hourly
weekly
monthly
annually
If salary is not paid hourly, is this a base wage?
yes
no
Are any commissions or bonuses included?
yes
no
Please specify the amounts that are commissions
or bonuses
Any owner/partner salary? If yes, please designate amt or %.
If employee not paid by a standard wage, explain how they are paid.
Was salary continued after date last worked?
yes
no If yes, please provide date salary continuance will be paid thru:
/
/
If salary was continued, was the amount paid the same as salary reported?
yes
no
If no, explain:
Please specify:
salary continuance
sick pay
vacation
PTO
other
Is employee eligible for or paying into State Disability Income?
yes
no
If yes, amount received: $
Effective date:
Is employee receiving a pension benefit under a plan sponsored by you, the employer?
yes
no
If yes, amount received: $
Effective date:
Is employee receiving any income from other sources you are aware of?
yes
no
If yes, amount received: $
Effective date:
Type of income:
Plan number 1023296
Unit number
Employer name
X
Date
Signature
Title
Telephone number
FAX number
Email address
GP60515-01
Page 1 of 7
05/2013
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