Fillable Request For Accident Only Policy Benefits Form (Page 4 of 4) in pdf

ONLY COMPLETE FOR ACCIDENT ONLY DISABILITY RIDER BENEFITS

INSURED STATEMENT

See page 1 for fraud statements and filing instructions.

1. Last date worked _________________________________________________________________________________________________________________________

2. Dates you were totally disabled From ____________________________________________

Thru _____________________________________________________

3. On what date did you return to work? Part time _____________________________________ Full Time __________________________________________________

4. If you have not yet returned to work, when do you anticipate returning to work? ________________________________________________________________________

5. Did the accident result from employment? _____________ Yes

_____________ No

6. If yes, are you filling or will you be filling for Workers’ Compensation? _____________ Yes

_____________ No

STATEMENT OF PHYSICIAN

1. Diagnosis and concurrent condition

ICDA code __________________________

(If diagnosis code other than ICDA used, give name)

2. Is condition due to injury arising out of patient’s employment? _____________ Yes

_____________ No

3. Date of services since disability

4. If patient hospitalized, give name and address of hospital and dates

commenced, not previously reported

_________________________________________________________________________

Name of hospital ________________________________________

_________________________________________________________________________

Address of hospital _______________________________________

_________________________________________________________________________

Admitted ____/____/____

Discharged ____/____/____

5. Date accident happened

6. Date patient first consulted you for this condition

7. Has patient ever had same or similar condition?

8. Is patient still under your care for this condition?

________ Yes

________ No

If yes, when and describe.

________ Yes

________ No

9. Patient was continuously and totally disabled?

10. Patient was partially disabled?

(unable to work)

From

Through

From

Through

11. If still disabled, date patient should be able to return to work.

12. Was there a referring physician? ______ Yes

______ No

If so, what is his name and address?

Date

Physician’s Name (Print)

Signature

Degree

Fax

Telephone

Street

City and State

Zip Code

Tax Identification #

STATEMENT OF EMPLOYER

Company Name

Phone No.

Name of Employee

What percentage of the employees premium is paid by the employer? ____%

Employee’s Title

$ ___________ Does the employee participate in Social Security?

q Yes

q No

q Weekly Salary

$ ___________ If no, hired after 4/1/1986?

q Yes

q No

q Monthly Salary

$ ___________ Are employee paid premiums for this policy withheld before or after taxes?

q Annual Salary

(if commissioned)

Before q

After q

Is this loss a result of employment? ______ Yes

______ No

Has the employee made claim for or is he entitled to

Worker’s Compensation? ______ Yes

______ No

Date employee last worked

Date returned to work

Give final date of paid sick leave to which employee is entitled

At the time of this disability was the employee?

q Full Time

q Part Time

q On Leave

q Retired

q No Longer Employed

(Check One)

Is employee eligible for any other paid compensation?

q Yes

q No

If yes, explain what type of benefit this is: Monthly Benefit ___________________

Period Eligible _______________

(Signature of Employer Representative)

(Date Signed)

BN-713-AWD-1011

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Request For Accident Only Policy Benefits Form Page 4

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