Maternity Disability Claim Form Page 2
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4PATIENT’S NAME: _________________________________________________________ Date of Birth: ______/_____/______
POLICY NUMBER(S): _______________________________________________________ Claim Number: _________________
ATTENDING PHYSICIAN’S STATEMENT:
To be completed and signed by the Attending Physician
ICD 9/10 Code: ___________Primary Diagnosis:
_________________________________________________________________________
ICD 9/10 Code: ___________Secondary Diagnosis:
_______________________________________________________________________
List any diseases or infirmity affecting the present condition(s
): _____________________________________________________________
Please list any complications of pregnancy: ______________________________________________________________________
Hospitalization:
Admission Date: _____/_____/_____
Discharge Date: _____/_____/_____
Hospital: _________________________________________________________ City: ________________________ State:
______
Last Menstrual Period: ____/____/____
Expected Due Date: _____/_____/_____
Delivery Date: _____/_____/_____
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Type of Delivery:
Vaginal
C-Section
The patient is UNABLE to perform their job duties: FROM: _____/_____/_____ THROUGH: _____/_____/_____
When is the patient expected to RESUME WORK?
Part Time/Partial Duties: _____/_____/_____
Full Time/Full Duties: _____/_____/_____
PHYSICIAN VERIFICATION:
Signed:
MD Date:
_______________________________________________________________________________,
______/______/______
Print Name: ________________________________________ Specialty: __________________ Phone #: __________________
Address:
City:
State: ______ Zip: __________
EMPLOYER’S STATEMENT:
To be completed and signed by your employer, if you are unemployed or self employed
please complete and sign this form.
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Employment Information/Job Description: If self employed, check this box
Employer/Company Name: __________________________________________________________________________________
Date of Hire: ____/____/____ Employee’s Job Title/Position: _______________________________________________________
Please attach a copy of the job description or list major job responsibilities.
Major Responsibilities: ______________________________________________________________________________________
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This job classification is:
Sedentary,
Light Work,
Medium Work,
Heavy Work,
Very Heavy Work.
Prior to inability to work, he/she worked ______ hours per week.
Hourly rate of pay: $________
Annual Salary: $___________
*If you are self employed, we may require proof of income. We will notify you if additional documentation is required.
Dates Missed Work / Returned to Work:
I hereby certify that ___________________________________ did not perform any part of his/her work from, _____/_____/_____
through _____/_____/_____.
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Did the employee work light duty or part time?
Yes
No If yes, what dates? _______________________________________
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When recovered, will he/she resume work?
Yes
No If no, why? ________________________________________________
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Has the employee returned to work?
Yes
No Part Time/Partial Duties: ____/____/____ Full Time/Full Duties on: ____/____/___
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Section 125:
Were the premiums for this Policy paid with pre-tax dollars under Section 125?
Yes*
No
*If yes, FICA withholding will be deducted from the disability claim payment
.
EMPLOYER VERIFICATION:
Signed by: _______________________________________ Date: ____/____/____ Print Name: ____________________________
Title: ______________________________________________
Company: ______________________________________
Address: ________________________________________________________________ Phone #: (______)_________________
Remember it is a crime to fill out this form with facts you know are false or to leave out facts you know are relevant and important.
Please check to be sure all information is correct before signing. Please refer to the fraud notice specific to your state.
ABJ16702-4
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