Disability Claim Form - Principal Financial Group Page 2
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7Job Description Questionnaire
Principal Life has dedicated staff who are available to both employees and employers to assist and answer questions on return to work. Please visit
our website at We will also be available to discuss the benefits of return to work for
you and your employee once the claim is filed.
Name:
Job title:
1.
A regular work day consists of
hours a day,
days a week.
In a regular work day, the employee’s job involves:
2.
Sitting
hours at one time.
hours during a regular work day.
Standing
hours at one time.
hours during a regular work day.
Walking
hours at one time.
hours during a regular work day.
Never – not applicable
Occasionally – up to 3 hours in an 8-hour day or 1-12 times per hour
Frequently – 3-6 hours in an 8-hour day or up to 12-60 times per hour
Continuously – 6-8 hours in an 8-hour day or 60 times per hour
Never
Occasionally
Frequently
Continuously
3.
Lifting
lbs.
lbs.
lbs.
Carrying
lbs.
lbs.
lbs.
4.
Hand Use
N
O
F
C
N
O
F
C
Simple grasping (left)
Simple grasping (right)
Power grasping (left)
Power grasping (right)
Pushing & pulling (left)
Pushing & pulling (right)
Fine manipulation
Keyboarding
(not keyboarding)
w.p.m.
5.
Reaching
N
O
F
C
N
O
F
C
At shoulder level
Above shoulder level
At waist level
Below waist level
6.
Positioning
N
O
F
C
N
O
F
C
Bends (waist level)
Twists (waist level)
Squats
Crawls
Kneels
Balancing
Climbs (ladders)
Climbs (stairs)
7.
Using feet for repetitive movements as in
left
right
both
operational functions:
yes
no
yes
no
yes
no
8.
Environment
yes
no
If yes, please describe.
Unprotected heights
Being around moving machinery
Exposure to marked changes in temperature and humidity
Exposure to dust, fumes and gases
Uses vibrating equipment
Walks on uneven terrain
Travels for work (if yes, by what means and how often)
9.
Technology
yes
no
If yes, please describe.
Operate automotive equipment (truck, forklift, etc.)
Office equipment (computer, 10-key, FAX, etc.)
Computer knowledge (software, E-mail, internet, etc.)
10. Remarks (Please add any additional requirements.)
11. If the Attending Physician for the employee listed above releases him/her will you be able to:
Accommodate part time work?
yes
no
possibly
Accommodate light duty work?
yes
no
possibly
X
Employer signature:
Title:
Date:
Please print name:
Phone number:
GP60515-01
Page 2 of 7
05/2013
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