Form Amr Di 0917 - Disability Claim Employee Statement
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12DISABILITY CLAIM
EMPLOYEE STATEMENT
Metropolitan Life Insurance Company
PLEASE PRINT OR TYPE
P.O. Box 14590
Lexington, KY 40511
Note to Employee: Complete all pages of this form and submit to MetLife at the address shown.
Failure to do so may result in a delay in your benefit decision.
Section 1: Personal Information
Name (Last, First, MI)
Employer
Social Security #
Address
City
State
Zip Code
Date of Birth (MM/DD/YY)
Gender
M M M F
mm/dd/yy
Home Phone #
Work Phone #
Job Title
How long at this
Marital Status
W4 Filing Status_____________________
position?
M Married
Number of Exemptions________________
M Single M Other
Dependent Information:
Name
Date of Birth
Social Security #
Spouse
____________________________________________________
________________________
mm/dd/yy
__________________________
Child(ren)
____________________________________________________
________________________
mm/dd/yy
__________________________
____________________________________________________
________________________
__________________________
mm/dd/yy
____________________________________________________
________________________
__________________________
mm/dd/yy
Section 2: Claim Information
Is your disability due to M Injury / Accident? M Illness? M Pregnancy? If due to injury / accident, give date, time and details. (When, Where, How)
Have you had previous absences from work due to this disability or another disability? M Yes M No
If yes, provide date and medical conditions.
Attach a separate sheet of paper to answer this question if needed.
mm/dd/yy
I (M have M have not) recovered from my Disability.
Return to Work:________________ Actual or Estimated (circle one) Date Recovered:________________
mm/dd/yy
mm/dd/yy
Is this condition work-related? M Yes M No
If condition is due to pregnancy, what is your estimated delivery date?______________________________
mm/dd/yy
Do you have sick time available? M Yes M No
If “Yes”, provide the number of available hours: _______________________________________________
Date of first treatment for this condition
Date Disability Began
Height
Weight
mm/dd/yy
mm/dd/yy
Name, address, phone number of your primary attending physician.
Name all physicians / providers who have treated you since the beginning of the disability. (Attach an additional sheet if more space is needed.)
Name of Physician / Provider
Phone Number
Dates of Treatment
Reason For Visit
____________________________________
From
To
__________________________________________
mm/dd/yy
mm/dd/yy
____________________________________
From
To
__________________________________________
mm/dd/yy
mm/dd/yy
____________________________________
From
To
__________________________________________
mm/dd/yy
mm/dd/yy
____________________________________
From
To
__________________________________________
mm/dd/yy
mm/dd/yy
Name and address of hospital
Circle Highest Education Level Completed (number of years).
Please describe what prevents you from performing the duties of your job.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Other positions / jobs held prior to current one
Have you applied for or are you receiving income from any other sources?
M Yes
M No
If yes, provide the following information
Applied for
Receiving
$ Amount
Frequency
From / To Dates
Salary Continuance / Sick Pay ............................................................ M
____________________
____________________
____________________
mm/dd/yy
mm/dd/yy
M
Short Term Disability ......................................................................... M
____________________
____________________
____________________
M
mm/dd/yy
mm/dd/yy
Worker’s Compensation .................................................................... M
____________________
____________________
____________________
M
mm/dd/yy
mm/dd/yy
State Disability .................................................................................. M
____________________
____________________
____________________
mm/dd/yy
mm/dd/yy
M
Social Security .................................................................................. M
____________________
____________________
____________________
M
mm/dd/yy
mm/dd/yy
Dependent Social Security ................................................................ M
____________________
____________________
____________________
mm/dd/yy
mm/dd/yy
M
No Fault (Income Replacement) ........................................................ M
____________________
____________________
____________________
mm/dd/yy
mm/dd/yy
M
Retirement / Pension ........................................................................ M
____________________
____________________
____________________
mm/dd/yy
mm/dd/yy
M
Permanent Total Disability (for Life Insurance) ................................. M
____________________
____________________
____________________
mm/dd/yy
mm/dd/yy
M
Unemployment Insurance ................................................................. M
____________________
____________________
____________________
mm/dd/yy
mm/dd/yy
M
Work Earnings from Any / All Sources .............................................. M
____________________
____________________
____________________
mm/dd/yy
mm/dd/yy
M
Other (Please Identify) ...................................................................... M
____________________
____________________
____________________
M
mm/dd/yy
mm/dd/yy
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AMR DI 0917 (02/14) Fs
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