Disability Claim Form - Principal Financial Group Page 5
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7Employee Statement
The Employee Statement must be accompanied by the Authorization for Release of Personal Health and other Information found on page 7
Your name
Date of birth
Soc Sec #
Your home address
(Street)
(City)
(State)
(ZIP code)
Home telephone number
Work telephone number
Cellular telephone number
Your email address
Date you became disabled
Is disability due to
accident
illness
Please describe accident in detail,
Including date, time and place of occurrence. If illness, nature of illness and date
If disability is the result of a motor vehicle accident, have you applied for or are you receiving No Fault/Auto Insurance Income Replacement benefits?
yes
no
If yes, date applied
Amt received $
Freq of pmts
Please include a copy of the police report and the auto agent’s carrier name, phone number and policy number:
Did disability result from employment?
yes
no
Have you filed a Worker’s Compensation claim?
yes
no
If yes, date filed for Worker’s Compensation
If approved, amount received $
Freq of pmts
(If Worker’s Compensation is approved or denied, please attach a copy of the award or denial letter with this claim.)
Do you have other insurance with our company?
yes
no
If yes, please list policy numbers:
Do you have other disability insurance with other companies?
yes
no
If yes, provide the following:
Name of company
Policy number/policy date
Benefit amount received per month
Is the coverage listed above:
Group coverage
Individual coverage
Indicate if you have applied for or are receiving any of the following benefits, date applied and benefit amount if approved (please send copy of award
letter or most recent benefit check stub.)
Type
Date Income Began
Amount
Type
Date Income Began
Amount
Social Security
Disability/Retirement/Widows
State Disability
Social Security Early Retirement
Pension
Unemployment
Other Income
Describe which duties and activities you are unable to perform as a result of your disability and why:
List the number of hours you spend each day in the following activities while working:
Sitting
hrs/day
Walking
hrs/day
Lifting
hrs/day
Average weight lifted
lbs
Standing
hrs/day
Traveling
hrs/day
Bending
hrs/day
Maximum weight lifted
lbs
Names of doctors, practitioners and hospitals
Telephone number
Date confined/consulted
Reason for confinement/consultation
I declare that all the above statements on this form are true and complete to the best of my knowledge.
X
(Signature of employee)
(Date)
I certify that I am a citizen of the following country:
X
(Country)
(Signature)
(Date)
This completed form may be faxed to Principal Life at 1-800-255-6609.
GP60515-01
Page 5 of 7
05/2013
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