Short Term Disability Report Form
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1IBEW Local 347 Electrical Workers
Health and Welfare Fund
PO Box 26068
Toll Free (844) 347-IBEW (4239)
Salt Lake City, UT 84126-0068
CompuSys of Utah, Inc.
Fax (801)973-1007
SHORT TERM DISABILITY REPORT
COVERED EMPLOYEE’S NAME ____________________________________________SOC. SEC __________________________
EMPLOYER
________________________________________________________________________________________
Part I – Covered Employee Certification (Please answer all questions)
1.
Date symptoms first appeared or accident occurred
_______________________________________________
2.
I certify that I have been continuously disabled and unable to perform my work since
_____________________
DATE
❑
❑
3.
Did sickness or injury arise from your employment?
Yes
No
❑
❑
4.
Is claim being made for workmen’s compensation?
Yes
No
5.
My last treatment was on __________________by
_____________________________________
DATE
DOCTOR
6.
I recovered or I expect to recover sufficiently to resume work on
__________
DATE
I understand that I am required to notify the Fund Office prior to or immediately upon the occurrence of one or more of the following events in
accordance with the following rules::
1)
I understand that I must provide written notice to the Fund Office before I engage in any employment;
2)
I understand that I must provide written notice to the Fund Office prior to the date that I receive unemployment insurance and/or
compensation payments;
3)
I understand that I must provide written notice to the Fund Office prior to the date that I receive Social Security Disability Benefits;
4)
I understand that I must provide written notice to the Fund Office prior to the date that I receive benefits from the National Electrical Benefit
Fund; and
5)
I understand that I must provide written notice to the Fund Office on the date that a physician determines that I am no longer unable to work
because of an injury or sickness.
I hereby certify that all information provided on this Short Term Disability Report is correct to the best of my knowledge. I understand that if
this information changes, or if any of the events listed in numbers (1), (2), (3), (4), or (5) above occurs, it is my responsibility to notify the
Fund Office immediately. I also understand that I will be required to reimburse the Plan for any payments made as a result of my failure to
notify the Fund Office in accordance with the rules described above.
Covered Employee Signature
_______________Date
__________
Present Address
__________
Part II – Doctor’s Certification (Please answer all questions)
1.
Diagnosis and Concurrent Conditions
__________
2.
Date patient first consulted you for this condition
__________
DATE
3.
The patient has been continuously disabled (unable to return to regular work) from
__________
DATE
4.
This Plan does not have a “light” duty release provision. Considering the claimant’s occupation, could claimant resume duties of his/her usual and
customary work while continuing treatment? ❑ Yes ❑ No
If no, please explain why ________________________________________________________________
____________________________________________________________________________________
5.
The patient recovered, or will recover, sufficiently to return to his regular job on
__________
DATE
6.
Since last report, this patient was hospitalized from
___ to
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
7.
Name of Hospital
__________
8.
Location (City & State)
__________
❑ Yes
❑ No
9.
Are you still treating patient?
Date of last treatment
Date of next appointment
__________
❑ Yes ❑ No
10. Did sickness or injury arise from patient’s employment?
Doctor’s Signature
Date
Address
____
Telephone
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