Spousal Disability Rider Claim Form Page 3
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4ATTN: AWD BENEFITS DEPT.
P.O. Box 268898
REQUEST FOR SPOUSAL
Oklahoma City, Oklahoma 73126
DISABILITY RIDER BENEFITS
Toll Free: 1-800-437-1011
Fax: 1-888-243-3453
EMPLOYER’S REPORT OF CLAIM
Name of Employer:
Phone No.:
(
)
Mailing Address: (include street, city, state and zip code)
Fax No.:
(
)
Name of Employee:
Social Security Number:
E
M
-
-
P
L
Address: (include street, city, state and zip code)
Phone No.:
O
(
)
Y
M
Date of Hire:
Occupation: (please attach job description)
E
N
T
Status of employment at time of disability:
o Full-Time
o Part-Time
o Leave of Absence
o Terminated
o Retired
Number of hours worked per week at time of disability:______________________
Has employee’s status of employment changed? o Yes o No If yes, current status and date of status-change? __________________
SALARY AT TIME OF DISABILITY
S
A
L
A
Annual: $_____________________ Effective Date: _________________________
R
Y
Date employee last worked:_______________________________
D
I
Has employee returned to work?
r Yes
r No
S
A
B
I
If Yes, date returned to work:
L
I
T
Y
Full Time: __________________________
Part Time: ________________________
Did Employee’s disability result from employment?
o Yes
o No
O
T
If yes, name, address and phone number of Worker’s Compensation carrier: _______________________________________________________
H
E
R
Has employee made a claim for or is entitled to Worker’s Compensation?
o Yes
o No
I
Does the employee have other group disability insurance? o Yes
o No
N
C
Name, address and phone number of any other disability carrier: (include street, city, state and zip code)
O
M
E
I hereby certify that the above named employee is a member of our Group Disability Program. The Information stated above is correct to the best of my
knowledge and belief.
Authorized signature of employer firm or authorized official: _________________________________________________________________________
Title: ______________________________________________________ Date: ________________________________________________________
E-mail Address:______________________________________________ Extension: ____________________________________________________
BN-717(AWD)-0712
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