Boston Mutual Claim Bd 1321 0706 Form PDF Details

Filing for disability benefits through Boston Mutual Life Insurance Company involves a detailed procedure that requires the careful completion of the Boston Mutual Claim Bd 1321 0706 form. This process is initiated once a disability occurs, and it's critical for claimants to meticulously fill out all sections of the claim form to prevent any unnecessary delays in the processing of their benefits request. The form encapsulates various segments that need attention—from the initial disability benefits claim form filled by the employee, to confirmation of the condition by the treating physician, as well as an employer’s statement regarding the employee's work status and compensation details. Additionally, submission options are flexible, allowing for both mailing and faxing of the completed forms to the provided addresses. Importantly, the form also includes sections on other potential income sources during disability and requires authorization for the release of medical information, underlining the comprehensive nature of the claim process. With detailed instructions and a warning against providing any false information, this form serves as a vital step in ensuring that those facing disabilities can receive their rightful benefits without delay.

QuestionAnswer
Form NameBoston Mutual Claim Bd 1321 0706 Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesboston life claim form, boston mutual life ins claim forms, boston mutual group forms, boston mutual life claim form

Form Preview Example

Boston Mutual Life Insurance Company

Group Disability

Claim Filing Instructions

IMPORTANT: All portions of this claim form must be completed after disability begins to avoid undue delay in processing claimant’s request for benefits. If you have any questions when completing this form, please call our:

Toll Free Number - (800) 320-4445

1.Complete "Employee - Initial Disability Benefits Claim Form" in full.

2.Have treating physician complete the "Physician - Initial Disability Claim Form" and return to you.

3.Have Employer complete the "Employer - Initial Claim Form" and return to you.

4.Submit all completed forms to the address below or you may fax all completed forms to our:

Toll Free Fax Number - (888) 594-5729.

Mail To:

Boston Mutual Life Insurance Company

Benefits Administration

P.O. Box 268956

Oklahoma City, OK 73126-8956

BD-1321-0706

Mail to: Boston Mutual Life Insurance Company

Benefits Administration

P.O. Box 268956

Oklahoma City, OK 73126-8956

Toll Free Phone # 1-800-320-4445

Toll Free Fax # 1-888-594-5729

EMPLOYER – INITIAL CLAIM FORM

Employee Name:

Occupation:

Social Security Number:

Hire Date:

STATUS OF EMPLOYMENT: Full Time: ❏

Part Time: ❏

Days per week: ________ Hours per day: _________

 

If employee’s status has changed, please check the appropriate box and provide change date below:

 

 

 

 

Lay Off: ❏

 

Leave of Absence: ❏

 

 

 

 

Terminated: ❏

Retired: ❏

 

PREMIUMS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are the employee’s disability premium contributions deducted pre-tax ❏ or post-tax ❏?

 

 

 

 

 

What percentage of the disability premiums do you pay?_________%

 

 

 

 

 

Are Social Security taxes withheld from employee’s pay check? Yes ❏ No ❏

 

 

 

 

 

Date that last disability premiums deducted from payroll:___________ Amount deducted: $__________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SALARY AT TIME OF DISABILITY:

 

 

 

 

 

 

 

 

 

 

 

Hourly: $_________

Weekly: $__________ Monthly: $__________

 

 

 

 

 

Annually: $__________________

$_____________________

 

 

 

 

 

 

W-2, previous calendar year

Year-to-date, current calendar year

 

 

 

 

 

Date last worked?______________________

 

 

 

 

 

 

 

 

 

 

 

Has employee returned to work? Yes ❏ No ❏ Return date: ________________ Full Time ❏ Part Time ❏

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is the employee receiving or eligible to receive any of the following?

 

 

Dates Benefits

 

 

Yes

No

Amount

 

Wk

Mo

 

Company Name and Phone Number

 

Begin

End

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Group

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Disability

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Salary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Continuation

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sick Leave

 

$

 

 

 

 

 

 

 

 

 

PTO/PPT

 

$

 

 

 

 

 

 

 

 

 

Other (Bonus, etc.)

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Retirement/Pension

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is disability the result of work related injury/illness? Yes ❏ No ❏

 

 

 

 

 

 

 

If yes, has a Workers' Compensation claim been filed? Yes ❏ No ❏

 

 

 

 

 

Please provide name and phone number of Workers' Compensation carrier:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Name:

 

 

 

 

 

 

 

 

 

Office Phone Number:

Fax Phone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address:

 

 

 

 

 

 

 

 

 

City:

State:

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form completed by: (please print)

 

 

 

 

 

 

 

Title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature:

 

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

This documents that the above statements are true and complete to the best of my knowledge.

 

BD-1321-0706

Mail to: Boston Mutual Life Insurance Company

Benefits Administration

P.O. Box 268956

Oklahoma City, OK 73126-8956

Toll Free Phone # 1-800-320-4445

Toll Free Fax # 1-888-594-5729

EMPLOYEE - INITIAL DISABILITY CLAIM FORM

WARNING: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim containing any false, incomplete, or misleading information may be guilty of insurance fraud and subject to criminal and civil penalties.

Name:

Social Security Number:

Date of Birth:

Complete Mailing Address:

Complete Resident Address:

Telephone Number:

Do you have dependents under age 18? Yes ❏ No ❏ If yes, please list dependent names and birth dates below:

1)Please list medical condition or injury causing disability:

2)If disability is the result of an accident, please explain where, when, and how accident happened:

3)Is your disability the result of your employment? Yes ❏ No ❏ If yes, please submit copy of Workers' Compensation award or denial letter.

4)Please list all dates of medical treatment pertaining to current disability:

5)Have you ever had or been treated for same or

similar condition? Yes ❏ No ❏ If yes, please explain:

6)Please list name and phone number of treating physician(s):

7)Date Last Worked:

Date Returned to Work:

8)If you have not returned to work, what is the anticipated return date?

Full Time: ______________________

Part Time:______________________

9)If your request for benefits is approved, do you want Federal Taxes withheld from each benefit check? Yes ❏ No ❏

If yes, please indicate dollar amount below:

(Minimum amount required is $87 per month.) $_______________

10) Please identify other income sources and amounts of income which you are receiving or may be entitled to receive during this disability:

Social Security - Disability ❏ Retirement ❏

Yes ❏

No ❏

$__________

V.A. Benefits

Yes ❏

No ❏

$___________

Dependent Social Security

Yes ❏

No ❏

$__________

Sick Leave or Wage Continuation

Yes ❏

No ❏

$___________

State Disability

Yes ❏

No ❏

$__________

Retirement (normal, early, or disability)

Yes ❏

No ❏

$___________

Other Group Disability Coverage

Yes ❏

No ❏

$__________

 

 

 

 

Include a copy of your award or denial letter from any source that you have received.

AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION

I hereby authorize the entities specified below to disclose any information about my entire medical record and history of treatment for physical and/or emotional illness

to include psychological testing, except psychotherapy notes, to individuals representing Boston Mutual Life Insurance Company (BMLIC) who are involved in determining whether I am eligible for benefits under my insurance coverage. Those so authorized are: a) licensed physicians or medical practitioners; b) hospitals, clinics or medically-related facilities; c) health plans; d) Veteran’s Administration; e) past or present employers; f) pharmacy; g) insurance companies; h) Social Security Administration; i) retirement systems; j) Department of Motor Vehicles, and k) Workers’ Compensation carrier.

NOTICE: Information authorized for release may include information on communicable or venereal diseases such as hepatitis, syphilis, gonorrhea, Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) or other conditions for which you may have been treated. This authorization excludes disclosure of the result of a test for HIV if you have tested HIV positive but have not developed symptoms of the disease AIDS. Such test results shall not be discovered or published. Nothing in the caveat will prohibit this authorization from including the fact that you have AIDS.

I understand that I may refuse to sign this authorization; however, if I do not sign the authorization, my failure to sign the authorization may result in a denial of benefits. I understand that I may revoke this authorization at any time by writing to Boston Mutual Life Insurance Company, Benefits Administration, P.O. Box 268956, Oklahoma City, Oklahoma 73126-8956 or calling toll free 1-800-320-4445. I understand that my right to revoke this authorization is limited to the extent that BMLIC has taken action in reliance on the authorization; or, the law provides BMLIC with the right to contest my insurance coverage or a claim under my insurance coverage. A copy of this authorization will be as valid as the original. I understand that if protected health information is disclosed to a person or organization that is not required to comply with federal privacy regulations, the information may be re-disclosed and no longer protected by federal privacy regulations.

For health insurance coverage, this authorization will expire twenty-four months from the date it is signed or upon termination of my insurance policy, whichever occurs first. For insurance coverage other than health insurance, this authorization will expire twenty-four months from the date it is signed or upon expiration of my claim for benefits, whichever occurs first. For Arizona residents, release of HIV/AIDS released information can only be disclosed for a period not to exceed 180 days from the date shown below.

Signature :____________________________________________ Print Insured’s/Patient Name: ______________________________________ Date:_______________

Please retain a copy for your personal records, or you may request a copy from our company.

BD-1321-0706

FAILURE TO SIGN & DATE FORM WILL DELAY BENEFITS

Mail to: Boston Mutual Life Insurance Company

Benefits Administration

P.O. Box 268956

Oklahoma City, OK 73126-8956

Toll Free Phone # 1-800-320-4445

Toll Free Fax # 1-888-594-5729

PHYSICIAN - INITIAL DISABILITY CLAIM FORM

Patient’s Name:

Social Security Number:

Date of Birth:

 

Diagnosis: Please list diagnosis resulting in patient’s temporary total disability (including complications)

 

 

Diagnosis: ________________________________________________________________

ICD9 Code: __________________________________

 

 

Diagnosis: ________________________________________________________________

ICD9 Code: __________________________________

 

 

 

 

 

 

 

 

Is disability the direct result of patient’s employment?

Yes No

 

 

 

 

 

 

 

 

 

 

Is disability the result of a pregnancy? Yes

No

If yes, date pregnancy was diagnosed:

 

 

 

 

 

 

 

 

 

Delivery date: (if delivered)

 

Expected delivery date: (if not delivered)

 

 

History: Was the patient referred to you?

Yes No Unknown If yes, please provide name and phone number of referring physician:

 

 

 

 

 

 

 

Date symptoms first appeared or accident happened?

 

Date patient first consulted you for this condition?

 

 

 

 

 

 

 

 

Are you aware if this patient has ever had the same or similar condition? Yes No If yes, please provide explanation including first date of onset.

Treatment: Is patient still under your care? Yes No If yes, date of next appointment: _____________________________________________

List all treatment dates:______________________________________________________________________________________________________

Please describe treatment plan: _______________________________________________________________________________________________

If patient is no longer under your care, please provide name and phone number of current physician:

Unknown

 

 

 

Has patient been confined to a hospital? Yes No

Admitted: ___________________________

Discharged: _____________________________

Hospital Name:

Phone Number:

 

 

 

 

If surgery is/was necessary, please list procedure(s):

 

 

 

 

 

Date scheduled:

Date performed:

 

Prognosis: Please list date(s) of temporary total disability (unable to work) From: ________________ Through: __________________

If patient is currently totally disabled, please indicate the anticipated length of disability by checking the appropriate box below:

Months:

or Permanently Disabled ❏ or Other

________________________

1

2

3

4

5

6

7

8

9

10

11

12

 

 

Impairment: List functional limitations/restrictions that render your patient temporarily totally disabled:

 

 

 

 

 

 

 

 

 

 

Attending Physician’s Name: (please print)

 

 

 

 

Degree:

 

Specialty:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address:

 

 

 

 

 

 

 

 

 

 

City:

 

State/Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

Office Phone Number:

 

 

 

 

 

 

 

 

Fax Phone Number:

 

Federal Tax ID Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form completed by:

Title:

Signature of Physician:

Date:

 

 

Attention Physician: This form documents your verification that the above named individual is totally disabled from their occupation. You will be asked periodically for updates related to the individual’s disability and treatment plan.

BD-1321-0706

How to Edit Boston Mutual Claim Bd 1321 0706 Form Online for Free

We were making this PDF editor with the concept of making it as easy to use as it can be. For this reason the entire process of completing the boston mutual life insurance company claims will likely to be easy as you go through these particular actions:

Step 1: Select the orange button "Get Form Here" on the website page.

Step 2: You're now on the document editing page. You can edit, add text, highlight selected words or phrases, put crosses or checks, and add images.

Fill in the boston mutual life insurance company claims PDF and provide the content for every single part:

boston mutual life claim form empty fields to fill out

Fill in the Yes No, Amount, Wk Mo, Company Name and Phone Number, Dates Benefits Begin End, Other Group Disability, Salary Continuation, Sick Leave PTOPPT Other Bonus, RetirementPension, Is disability the result of work, If yes has a Workers Compensation, Please provide name and phone, Employer Name, Street Address, and Form completed by please print fields with any particulars that is demanded by the software.

Filling out boston mutual life claim form part 2

Write down the essential particulars in Signature, Date, and This documents that the above box.

Filling out boston mutual life claim form stage 3

The area Name, Social Security Number, Date of Birth, Complete Mailing Address Complete, Telephone Number, Do you have dependents under age, Please list medical condition or, If disability is the result of an, Is your disability the result of, Please list all dates of medical, to current disability, Have you ever had or been treated, Please list name and phone number, Date Last Worked, and If you have not returned to work is where to include all sides' rights and responsibilities.

stage 4 to completing boston mutual life claim form

End by reading the following fields and filling in the appropriate data: Date Returned to Work, Full Time Part Time, If your request for benefits is, If yes please indicate dollar, Minimum amount required is per, Please identify other income, Social Security Disability, Yes No Yes No Yes No, VA Benefits Sick Leave or Wage, Yes No Yes No Yes No, Include a copy of your award or, AUTHORIZATION TO USE OR DISCLOSE, I hereby authorize the entities, NOTICE Information authorized for, and I understand that I may refuse to.

boston mutual life claim form Date Returned to Work, Full Time   Part Time, If your request for benefits is, If yes please indicate dollar, Minimum amount required is  per, Please identify other income, Social Security  Disability, Yes  No   Yes  No   Yes  No, VA Benefits Sick Leave or Wage, Yes  No  Yes  No  Yes  No, Include a copy of your award or, AUTHORIZATION TO USE OR DISCLOSE, I hereby authorize the entities, NOTICE Information authorized for, and I understand that I may refuse to blanks to complete

Step 3: Hit the "Done" button. At that moment, it is possible to export the PDF document - upload it to your electronic device or deliver it through email.

Step 4: Just be sure to generate as many copies of your form as possible to remain away from possible problems.

Watch Boston Mutual Claim Bd 1321 0706 Form Video Instruction

Please rate Boston Mutual Claim Bd 1321 0706 Form

1 Votes
If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .