Claim For Continuing Credit Disability Benefits Form
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1
2Claim For Continuing
Mail To: FAMLI
Claims Department
Credit Disability Benefits
14000 SW 119th Avenue
Miami, FL 33186
Financial American Life Insurance Company
Phone: 1-877-522-7343
A Member of the Cardif Group
SECTION A - STATEMENT OF CLAIMANT (Please Print)
Claim Number
Name
Telephone Number
I I I I I I
I I I I I I
I I I I I I I I
–
–
Street Address (Complete only if your address has changed)
City
State
Zip
Are you working?
Yes
No
If Yes, date work began ______/______/______ If No, what date do you anticipate returning to work? ______/______/______
Have you retired?
Yes
No
If Yes, provide date ______/______/______
Reason___________________________________________________________________________________
Have you applied for, or are you now receiving, Social Security Disability Benefits?
Yes
No If Yes, Date of award ______/______/______
Attach a copy of your award letter.
Have you applied for, or are you now receiving, any disability benefits including Workers’ Compensation?
Yes
No
______/______/______
Signature of Claimant
Date
SECTION B - STATEMENT OF ATTENDING PHYSICIAN (Please Print)
D
Note: If you are seeing this patient for the first time, please skip Section B and complete Section C on the reverse side. If this patient has been under
i
a
your care and treatment since first filling claim for benefits, please continue and complete only Section B.
g
n
Diagnosis (including any complications). Include ICD 9 code
o
s
i
s
T
A. A. Date of last visit
B. Date of next visit
C. Frequency of visits
r
e
______/______/______
______/______/______
a
t
D. Describe current and future treatment plan (including surgery and medications prescribed, if any.) Provide all applicable dates.
m
e
n
t
A. Has patient
B. Is patient
Recovered
Improved
Unchanged
Retrogressed
Ambulatory
Bed Confined
House Confined
Hospital Confined
P
C. If unchanged or retrogressed, please explain:
D. When will patient:
r
o
Return to Patient’s Occupation
1–3 mos.
3–6 mos.
6–12 mos.
more than 12
Never
g
Return to Any Occupation
1–3 mos.
3–6 mos.
6–12 mos.
more than 12
Never
r
e
E. Has patient been admitted to a hospital?
F. Name and address of hospital
s
Yes
No
If Yes, confined from
s
______/______/______to______/______/______
Cardiac (if Applicable)
C
A. Functional Capacity
B. Therapeutic Class (Activity)
C. Blood pressure last visit
l
(American Heart Assn.)
Class 1 (no limitation)
Class 3 (marked limitation)
A. (no restric.)
C. (moderate restric.)
a
Class 2 (slight limitation)
Class 4 (complete limitation)
B. (slight restric.)
D. (marked restric.)
_________________________________
s
s
E. (complete restric.)
Systolic/Diastolic
i
f
Physical Impairment (*As defined in federal dictionary of occupational titles)
Remarks:
i
Class 1 - No limitation of functional capacity; capable of heavy work.* No restrictions. (0–10%)
c
a
Class 2 - Medium manual activity.* (15–30%)
t
Class 3 - Slight limitation of functional capacity; capable of light work.* (35–55%)
i
Class 4 - Moderate limitation of functional capacity; capable of clerical/administrative (sedentary*) activity. (60–70%)
o
n
Class 5 - Severe limitation of functional capacity; incapable of minimum (sedentary*) activity. (75–100%)
A. Does patient currently have
B. Describe specific limitations and/or restrictions
P
Limitations/restrictions from:
r
o
Patient’s Occupation:
Yes
No
g
Any Occupation:
Yes
No
n
o
C. If the limitations and/or restrictions can be accommodated, would you release patient to return to work?
Yes
No
D. Date employment could begin
s
i
If Yes:
Part time
Full time
If No, explain:
______/______/______
s
Are you, the physician, related to this
patient?
Yes
No
If Yes, what is the relationship?
Name of Attending Physician - PLEASE PRINT
Degree & Specially
Telephone Number
I I I I I I
I I I I I I
I I I I I I I I
–
–
X
______/______/______
Fax Number
I I I I I I
I I I I I I
I I I I I I I I
Signature of Attending Physician (The above statements are true and complete to the best of my knowledge.)
Date
–
–
(Stamped signature is not acceptable.)
ASP (4/06)
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