Form Amr Di 0917 - Disability Claim Employee Statement Page 6
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12DISABILITY CLAIM
Metropolitan Life Insurance Company
EMPLOYER STATEMENT
P.O. Box 14590
Lexington, KY 40511
PLEASE PRINT OR TYPE
Note to Supervisor:
Complete all sections below and submit to MetLife at the address
shown. Failure to do so may result in a delay in employee’s benefit
decision.
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.
TO BE COMPLETED BY LOA/FIELD SUPERVISOR
Employee Name (Last, First, MI)
Social Security #
Employee ID #
Subsidiary or Work Group Employee (check one box) M Flight Attendant M Transport Workers Union M Pilot
M Management
M Support Staff
Company: M American Airlines M American Eagle
Occupation / Job Title - Please attach written job description, including the essential job functions.
_____________________________________________________________________________________________________________________
Work Location Address (Including state where employment is based)
Supervisor Name_______________________________________________________________ Supervisor Phone #_________________________
Address_______________________________________________________________________________________________________________
Supervisor E-Mail Address________________________________________________________________________________________________
Employee last day physically at work
Last Date Paid
Average Hours Worked Per Week.
(prior to disability)
mm/dd/yy
mm/dd/yy
Does the Employee have sick time available?
M Yes
M No
If “Yes”, provide number of available hours: ______________________
Has the employee filed a claim for Worker’s Compensations benefits? M Yes M No
Has an accident report been filed? M Yes M No
If yes, provide name and address of Worker’s Compensation Carrier.
Name______________________________________________________________________________ Phone #____________________________
Address____________________________________________________________________________ FAX #______________________________
Contact Person’s Name_______________________________________________________ Worker’s Comp. Claim # ________________________
Date Returned To Work
M Actual
M Estimated
mm/dd/yy
Are you able to accommodate Transitional Duty to return to work?
M Yes M No
If yes, describe below.
Has return to work been discussed with employee? M Yes M No
If you have questions or other information pertinent to this claim, please contact MetLife at 1-888-533-6287
Page 6 of 12
AMR DI 0917 (02/14) Fs
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