1199 Notice Proof Of Claim For Disability Form – Fill Out and Use This PDF

1199SEIU National Benefit Fund

498Seventh Avenue, New York, NY 10018-0009 • Tel: (646) 473-9200 • Outside NYC Area Codes: (800) 575-7771 Email: DBLClaims@1199Funds.org • www.1199SEIUBenefits.org

Notice and Proof of Claim for Disability Benefits

Healthcare provider must complete Part B on reverse side; Employer must complete Part C (Attachment)

MEMBER : PL E ASE RE A D THE FOL L OWING INS TRUC TIONS CA REFUL LY

1.Use this form only if you become sick or disabled while employed or if you become sick or disabled within four (4) weeks after termination of employment. Use green Claim Form DB-300 if you become sick or disabled after having been unemployed more than four (4) weeks.

2.You must complete all items of the Member’s Statement (Part A). Please be accurate. Please check all dates.

3.Be sure to date and sign your claim (see item 12). If you cannot sign this claim form, your representative may sign on your behalf. In that event, the representative’s full name, address and relationship to you should be noted under the signature.

4.Do not mail this claim unless your healthcare provider completes and signs Part B. You must complete the member’s section at the top of Part C, and then mail it to your employer.

5.Your completed claim and Employer’s Statement (Part C) should be mailed to the 1199SEIU National Benefit Fund within thirty (30) days after you become sick or disabled.

6.Make a copy of this completed form for your records before you submit it to the 1199SEIU National Benefit Fund.

PA R T A : MEMBER’S S TATEMENT ( PL E ASE PRINT IN BL ACK OR BL UE INK . PL E ASE A NSW ER A L L QUE S TIONS . )

1.Member’s full name: ________________________________________________________________________________________________________

2.Member’s ID #: _____________________________________ Home phone: ______________________________ Cell phone:____________________

3.Address: _________________________________________________________________________________________________________________

City: ______________________________________________ State:________________ Zip code: ____________ (Check box if new address)

6.My disability is (if it is an injury, please also state how, when and where it occurred): _______________________________________________________

________________________________________________________________________________________________________________________

a. Are you taking legal action?  No  Yes If "yes," lawyer’s full name:___________________________________________________________

Lawyer’s address:___________________________________________________________

___________________________________________________________

7. Date I became disabled: _________________ a. I worked on that day.  No  Yes b. I have since worked for wages or profit.  No  Yes

If "yes," list dates: ___________________________________

8.Please list information about your last employer. If you had more than one employer in the last eight (8) weeks, list all employers.

9.My job title is or was: _______________________________________________________________________________________________________

(Name of Union & Local #, if you are a member): __________________________________________________________________________________

10.For the period of disability covered by this claim:

If “yes” is checked for any of the items a, b, c(1), c(2), c(3), c(4) or c(5), fill in the following:

I have  received  claimed from _______________________________, for the period of __________________ to ___________________.

11. I have received disability benefits for another period of disability within the 52 weeks immediately before my present disability began.  No  Yes

If “yes,” fill in the following: I have been paid by _____________________________, for the period of __________________ to ___________________.

12.I have read the instructions above. I hereby claim disability benefits and certify that for the period covered by this claim I was disabled, and that the foregoing statements, including my accompanying statements, are to the best of my knowledge, true and complete. I authorize the release to or by the

1199SEIU National Benefit Fund of any medical information necessary to process this claim.

Member’s signature X__________________________________________ Date: ________________________

If signed by someone other than the member, please print the representative's full name, address and relationship to the member:

Full name: _____________________________________________________________________ Relationship: _______________________________

Address: ________________________________________________________________________________________________________________

City: _________________________________________________________ State: _______________________ Zip code: _____________________

1199SEIU National Benefit Fund

498Seventh Avenue, New York, NY 10018-0009 • Tel: (646) 473-9200 • Outside NYC Area Codes: (800) 575-7771 Email: DBLClaims@1199Funds.org • www.1199SEIUBenefits.org

Please Print in Black or Blue Ink

IMPORTANT: Use this form only if the member becomes sick while employed or becomes sick or disabled within four (4) weeks after termination of employment. Use green Claim Form DB-300 if the member becomes sick or disabled after having been unemployed more than four (4) weeks.

1199SEIU National Benefit Fund

498Seventh Avenue, New York, NY 10018-0009 • Tel: (646) 473-9200 • Outside NYC Area Codes: (800) 575-7771 Email: DBLClaims@1199Funds.org • www.1199SEIUBenefits.org

PART C : EMPLOYER'S STATEMENT

Member: Please complete the following four (4) lines. (Please print in black or blue ink . )

Date: ___________________________________________________________________

Member’s full name: _______________________________________________________

Member's ID #: ___________________________________________________________

Date disability began: _______________________________________________________

DISCLOSURE OF INFORMATION: The Worker's Compensation Board (WCB) will not disclose any information about your case to any unauthorized party without your consent. If you choose to have such information disclosed to any unauthorized party, you must file with the board an original signed Form OC-110A, Claimant’s Authorization to Disclose Workers’ Compensation Records, or an original signed, notarized authorization letter. You may telephone your local WCB office to have Form OC-110A sent to you, or may download it from www.wcb.ny.gov/content/main/forms/AllForms.jsp. Mail the completed authorization form or letter to the address given on Form OC-110A.

HIPAA NOTICE: In order to adjudicate as a Workers’ Compensation claim, WCL 13-a(4)(a) and 12 NYCRR 325-1.3 require healthcare providers to regularly file medical reports of treatment with the board and the carrier or employer. Pursuant to 45 CFR 164.512, these legally required medical reports are exempt from HIPAA’s restrictions on disclosure of health information.

ATTENTION: PAYROLL DEPARTMENT

The above member (your employee) is in the process of filing a claim for disability benefits with the 1199SEIU National Benefit Fund. Since you are the member's present employer, you are required by the Union contract and the Trustees of the 1199SEIU National Benefit Fund to promptly complete the “Employer’s Statement” below and return the completed form to the employee.

EMPLOYER'S STATEMENT (TO BE COMPLETED BY THE EMPLOYER. PLEASE PRINT IN BLACK OR BLUE INK.)

1.Date employee was employed: ___________________________________________ Employee's regular weekly wage: $_____________

2.Date employee last worked (before disability): ________________________________________________________________________

a.Full sick pay received (not the 1/3 sick pay provided in the Union contract), for the period of_________________ to ________________ .

b.Vacation pay received, for the period of ________________to ________________. Number of days of sick pay received: __________

5.Full name of employer (please give correct business name): ______________________________________________________________

6.Authorized signature X _________________________________ Date: ______________________________

7.Job title: __________________________________________________________________ Business phone: _____________________

8.Weekly Wages: List the employee's gross earnings during each of the last eight (8) calendar weeks prior to the week in which disability began.

1199SEIU BENEfiT AND PENSION FUNDS

498 Seventh Avenue • New York, NY 10018-0009 • Tel: (646) 473-6710 • Fax: (646) 473-6768 • www.1199SEIUBenefits.org

Direct Electronic Deposit Authorization for Disability Benefits

(Please allow a minimum of two (2) weeks for this authorization to be processed.)

Please note that a new authorization is required for each new (unique) disability claim.

Please print clearly in black or blue ink, or complete online. Remember to sign and date this form or it will not be valid.

________________________________________________________________________________________________________________

MEMBER’S FULL NAMEMEMBER ID #

________________________________________________________________________________________________________________

MEMBER’S ADDRESSCITYSTATEZIP CODE

________________________________________________________________________________________________________________

Election of Direct Deposit – you must sign and date this form to make any change (CHOOSE ONE):

New disability benefits direct deposit

Change from my current financial institution to the financial institution listed below

I am staying with my financial institution, but my account information has changed

Cancel my direct deposit and send my checks to my home address listed above

For direct deposit into a checking account: Requires a voided check with the account holder’s name pre-printed on the check; a stamp from the financial institution on this form; or a signed letter from the financial institution on company letterhead confirming the account holder, routing number and account number.

For direct deposit into a savings account: Requires a stamp from the financial institution on this form or a signed letter from the financial institution on company letterhead confirming the account holder, routing number and account number.

For banks in foreign countries or banks that do not accept direct deposit: Your check will be mailed directly to your home address.

Until further written notice from me, I hereby authorize the 1199SEIU Benefit and Pension Funds (“the Funds”) to: (a) deposit my disability payment amount in my account, chosen above; and (b) make adjustments and have my account charged for any erroneous credits or other amounts to which I am not entitled.

I further understand that should I close or change this account, I must give a new completed form to the Disability Department at least two (2) weeks before the disability direct deposit is to be terminated. I understand that direct deposit is a completely voluntary service provided by the Funds for my convenience, and that it can be terminated by the Funds or by me at any time. Because the wrong number can lead to my disability payment being sent to the wrong person’s account, I understand that I must ensure my account type, account number and routing number are all correct.

X ____________________________________________________________________________________________________________