DISABILITY CLAIM FOR
ACCIDENT & SICKNESS (A&S)/
Metropolitan Life Insurance Company
SHORT TERM DISABILITY (STD)/SALARY CONTINUANCE
P.O. Box 14590
Instructions for completing the claim form:
Lexington, KY 40512
1. Complete all applicable areas of the claim form. Please print clearly.
2. Please sign – a) bottom of this page and b) Fraud Statement.
Fax: 1-800-230-9531
3. Faxing this claim form will expedite receipt and eliminate your need to mail it.
New York – Any person who knowingly and with intent to defraud any insurance company or other person files an application
for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject
to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Section 1: To Be Completed by the Employer
Name of Employer
Group Report #
Sub-Code # (Sub-Division) Sub-Point # (Branch)
Address
City
State
Zip Code
Subsidiary or Division Name
Contact Person’s Name
Phone #
Contact Person’s E-mail Address
FAX #
Employee Name (First, MI, Last)
Social Security No.
Employee ID #
Date of Hire
Job Title
Job Class
mm/dd/yy
Sedentary
Light
Medium
Heavy
Very Heavy
Work Location Address
Work Phone #
Home Phone #
Supervisor Name
Supervisor’s E-Mail Address
Phone #
Is condition work related?
Yes
No.
If yes, provide: W/C Carrier Name
W/C Contact Person’s Name
Phone#
Worker’s Comp Claim #
Date Last
First Date
Date Returned To Work
Eff. Date of
Basic Earnings (exclusive of overtime, bonus, etc.)
Worked
of Absence
Coverage
Actual
$
Estimated
Hourly
Weekly
Bi-weekly
Monthly
Annual
mm/dd/yy
mm/dd/yy mm/dd/yy
mm/dd/yy
Benefit
Premium contributions
Payroll Classification
Exempt
Non-Exempt
Salaried
Hourly
Pre-Tax
Amount
Employer
% Employee
%
Post-Tax
Union
Non Union
Other
Employee’s Status As Of
Active
Vacation
Hours Worked Per Week
Full Time
Part Time
First Day Absent
LOA
Laid Off
Scheduled Work Week
M
Tu
W
Th
F
Sa
Su
Terminated
Retired
Is work week regular
or variable
If other than Active, please explain
If STD buy up, date enrollment card signed
LTD Coverage?
Yes
No
mm/dd/yy
Can employee’s job be modified/accommodated?
Yes
No
If yes, please describe.
Has return to work been discussed with
employee?
Yes
No
To the best of your knowledge, indicate if the employee has filed for or is receiving income from any of the following sources:
Applied for Receiving
$ Amount
Frequency
From/To Dates
mm/dd/yy
mm/dd/yy
Salary Continuance/Sick Leave
mm/dd/yy
mm/dd/yy
Workers’ Compensation
mm/dd/yy
mm/dd/yy
State Disability
mm/dd/yy
mm/dd/yy
Other (Please identify)
Provide weekly deduction amounts, if applicable:
Pre Tax
Post Tax
$ Weekly Amount
Medical
Life
Dental
LTD
Other (Please identify)
Authorizing Signature
Date
mm/dd/yy
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