Notice Of Disability Form - Supplemental Sickness Benefit Plan
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1NOTICE OF DISABILITY FORM
Supplemental Sickness Benefit Plan
AETNA
is the claim administrator for your Railroad Supplemental Sickness Benefit Plan
AETNA
P.O. BOX 189145
Within 60 days of your first day absent from work call 1-800-205-7651
PLANTATION, FLORIDA 33318-9145
PHONE: (800) 205-7651
or complete & mail or fax this form.
FAX: 860-907-4423
SECTION I THIS SECTION MUST BE COMPLETED BY OR ON BEHALF OF THE EMPLOYEE FOR ALL CLAIMS
Name of Employee (Please Print)
Date of Birth
Social Security Number
Employee Number
Employee’s Address
(Street)
(City)
(State)
(Zip)
Telephone Number
Hire Date
(
)
Name of Employer
Indicate which Organization represents you:
___ARASA
Department Last Worked
Location Last Worked
Electrical Workers
Boilermakers, etc.
Maintenance of Way
Signalmen
Railway Carmen
Firemen & Oilers
Date You Last Worked
Next Scheduled Work Day
Machinists & Aerospace
Sheet Metal Workers
Other ______________
Rate of Pay (per hr./ per month)
Occupation
$
Date You Became Disabled
Supervisor’s Name
Telephone No.
(
)
Name of All Treating Physicians
Telephone No.
Indicate Cause of Disability
1.
(
)
Accident (Complete Part II)
Sickness
Have you returned to work?
Yes
No
2.
(
)
If Yes, provide your return to work date
_________________________
If No, when do you expect to return to work? _________________________
3.
(
)
Have you received vacation pay since your last day worked?
Yes
No
4.
(
)
If Yes, provide date(s) _____________________________________________
Date of First Treatment
Do you hold any of the following certifications?
Yes
No
DOT
CRANE
CDL
Other ________________
If Yes, Have you been medically certified to return to work?
Yes
No
Have you completed a total of at least 12 calendar months of employment
Did you work for the Employer named above (or take vacation with pay) in
with one or more participating railroads?
Yes
No
the month before you became disabled?
Yes
No
SECTION II TO BE COMPLETED ONLY IF ACCIDENT INVOLVED
Date of Accident
Were you at work when accident happened?
Yes
No
If yes, for whom? _______________________________________________________
Explain how accident happened?
Was a railroad off-track vehicle involved?
Did injury result from a traffic accident?
Will a liability claim be made?
Yes
No
Yes
No
Yes
No
SECTION III THIS SECTION MUST BE COMPLETED BY OR ON BEHALF OF THE EMPLOYEE FOR ALL CLAIMS
Benefits under the Railroad Unemployment Insurance Act:
1. Have you applied for sickness benefits under the Railroad Unemployment Insurance Act?
Yes
No
2. If not, why not?
I am not qualified under the Act
My benefits have exhausted for this benefit year
Other _____________________________________________________________________________________________
Other Income Benefits:
1. Are any of the “Other Income Benefits” listed below available to you while disabled?
Yes
No
(If yes, check each of the following that apply, and show the monthly amounts payable)
Railroad Retirement Act – Disability Annuity
$ ________________
Social Security Act
Because of Age
Because of Disability
$ ________________
Military Pension
Because of Years of Service
Because of Disability
$ ________________
Wage Continuation
$ ________________
Off-Track Vehicle Agreement
$ ________________
Protective Agreement
$ ________________
Advancement from possible settlement with Railroad
$ ________________
Any other plan toward the cost of which any employer has contributed. (Specify) _______________________________________________________
FRAUD STATEMENT
If your application for benefits includes information that you know is false or misleading, you may be subject to criminal and civil penalties for fraud.
Penalties may include imprisonment, fines, and denial of benefits. You may also be required to pay damages and could be subject to discipline by your
employing railroad.
EMPLOYEE SIGNATURE: ______________________________________________________________________
DATE: _________________________
You may file your claim over the telephone by calling: 1-800-205-7651, by mail, fax,
or via the World Wide Web by logging onto: https://
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