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GROUP WEEKLY INCOME SUPPLEMENTARY REPORT

NOTICE TO EMPLOYEE: THIS FORM IS TO BE COMPLETED AND MAILED TO NORTH AMERICA ADMINISTRATORS, L.P ., P .O. BOX 1984, NASHVILLE, TN 37202, UPON

RETURN TO WORK OR THE DATE SHOWN BELOW WHICHEVER OCCURS FIRST.

SOCIAL SECURITY #

DATE OF BIRTH

GROUP NAME

NAME

LAST

FIRST

MIDDLE

EMPLOYEE’S ADDRESS

AUTHORIZATION TO RELEASE INFORMATION

I HEREBY AUTHORIZE ANY HOSPITAL, PHYSICIAN, MEDICAL PRACTITIONER, CLINIC, OR OTHER MEDICAL RELATED FACILITY TO DISCLOSE OR FURNISH

TO NORTH AMERICA ADMINISTRATORS, LP , ITS SUBSIDIARIES OR REPRESENTATIVES, ANY AND ALL INFORMATION WITH RESPECT TO ANY ILLNESS

(INCLUDING MENTAL ILLNESS) OR INJURY, AND COPIES OF ALL APPLICABLE RECORDS THAT MAY BE REQUESTED. I ALSO AUTHORIZE MY EMPLOYER

TO DISCLOSE ALL INFORMATION NEEDED TO PROCESS MY CLAIM.

THE INFORMATION PROVIDED TO NORTH AMERICA ADMINISTRATORS, LP , ITS SUBSIDIARIES OR REPRESENTATIVES, IS TO BE USED SOLELY FOR THE

ADMINISTRATION OF CLAIM(S) AS CAPTIONED ABOVE. A PHOTOSTATIC COPY OF THIS AUTHORIZATION IS TO BE CONSIDERED AS VALID AS THE ORIG-

INAL AND IS EFFECTIVE FOR THE DURATION OF THE CLAIM.

SIGNED __________________________________________________________________________________________________ DATE ________________________________

PHYSICIAN’S REPORT

(1) PATIENT’S NAME ____________________________________________________________________________________________________________ AGE ___________

(2) NATURE OF SICKNESS OR INJURY (DESCRIBE COMPLICATIONS, IF ANY)________________________________________________________________________

________________________________________________________________________________________________________________________________________________

(3)

(A) DATE OF FIRST TREATMENT ________________________________________________________________________ 20________

(B) DATE OF MOST RECENT TREATMENT ________________________________________________________________ 20________

(4) THE PATIENT HAS BEEN CONTINUOUSLY DISABLED (UNABLE TO WORK) FROM _____________________ 20_____ THROUGH__________________ 20_____

IF STILL DISABLED, WHEN SHOULD PATIENT BE ABLE TO RETURN TO WORK? _____________________________________________________ 20_____

(5) REMARKS: __________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________

SIGNED BY_____________________________________________________________________________ DEGREE______________________ DATE____________________

ADDRESS__________________________________________________________________________________________________________ TELEPHONE #______________

EMPLOYER’S REPORT

CURRENT SALARY/WAGES: $ ____________________________

DATE LAST WORKED _________________________20_______ Ë A.M. Ë P .M.

PER Ë YEAR Ë WEEK Ë HOUR (_____ HRS./WEEK)

IS THERE ANY POSSIBILITY THIS WAS CAUSED BY EMPLOYMENT Ë YES Ë NO IF YES, EXPLAIN _________________________________________________

HAS EMPLOYEE RETURNED TO WORK? Ë YES Ë NO

DATE WORK RESUMED_______________________________________20____

IF “NO” IS CHECKED ABOVE, DO YOU EXPECT EMPLOYEE TO RETURN TO WORK? Ë YES Ë NO

IF “YES” IS CHECKED ABOVE, GIVE APPROXIMATE DATE ______________________________________20_____

DATE ___________________________________________ EMPLOYER ____________________________________________________________________________________

SIGNED BY_______________________________________________________________________________________

Group Weekly Income Supplementary Report Form - Authorization To Release Information