Form Si 3379 Cta – Fill Out and Use This PDF

The SI 3379 CTA form, provided by Standard Insurance Company, is a comprehensive document designed for individuals seeking to file a claim for disability benefits. Designed to be meticulous, it requires applicants to fill out every space with relevant information or mark it as "NA" if not applicable, ensuring a thorough and speedier processing of the claim. This form includes sections such as the Employee’s Statement, Authorization to Obtain and Release Information, the Attending Physician’s Statement, and the Employer’s Statement, each necessary for the complete evaluation of the claim. To start filing your claim, click the button below.

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Form Si 3379 Cta PDF Details

The Si 3379 CTA form is an essential document designed by Standard Insurance Company for individuals seeking to apply for disability benefits, particularly those affiliated with CTA Benefits and Services. This comprehensive form is part of a disability benefits claim packet that meticulously guides applicants through the process of filing a claim. Applicants are required to engage with four distinct forms, each playing a pivotal role in the application process. The Employee’s Statement is the cornerstone of the application, demanding thorough responses to all inquiries, including specifics about injuries, illnesses, or pregnancies that lead to disability claims. To prevent delays, every part of these forms must be completed, with instructions advising to mark sections that aren't applicable with "NA" to indicate no oversight. Furthermore, the form emphasizes the necessity of attaching supporting documents such as Social Security or Workers’ Compensation benefit determinations to aid in the accurate calculation of monthly benefits. Additionally, the inclusion of the Authorization to Obtain and Release Information, alongside a separate authorization concerning psychotherapy notes, underlines the form’s comprehensive approach to gathering relevant information. This is further supported by the need for statements from Attending Physicians and Employers, to furnish a multi-faceted view of the claimant’s situation. These documents combined ensure that Standard Insurance Company has a holistic understanding of the claim, thereby facilitating a smoother review process. The detailed structure of the Si 3379 CTA form showcases the rigorous approach adopted by Standard Insurance Company in administering disability benefits, highlighting their commitment to providing clarity and support to applicants throughout the process.

Question	Answer
Form Name	Form Si 3379 Cta
Form Length	17 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	4 min 15 sec
Other names	notied, insurer, CALIFORNIA, si3379cta

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Standard Insurance Company – CTA Beneﬁts and Services PO Box 2773 Portland OR 97208

Tel 800.522.0406 Fax 888.414.0390

Disability Beneﬁts Claim Packet Instructions

PLEASE READ CAREFULLY

Your application for beneﬁts consists of four forms. Every space on these forms should be ﬁlled in to avoid delay in processing your application. If a section does not apply, or information is not available, “NA” should be written in the space so that we know you did not overlook that particular question. If a form is received incomplete, it may be returned for completion.

The four forms are:

1.The Employee’s Statement

●Answer every question completely. Be sure to use the appropriate section for injury, sickness or pregnancy. If a question does not apply to you write “NA”.

●

Use an additional page, if necessary, to give full and complete answers.

Attach copies of any Social Security, Public Employees Retirement System, State Teachers Retirement System, Workers’ Compensation or other beneﬁt determinations you have received. If you have applied for any other beneﬁts but have not yet received them, please send a copy of the application receipt. This information is needed to accurately calculate your monthly beneﬁts. If you are unable to make copies of these documents please send the originals. We will photocopy and return them to you promptly.

●Remember to sign and date your statement. An unsigned or undated statement will be returned to you.

2.The Authorization to Obtain and Release Information

The Authorization to Obtain and Release Psychotherapy Notes

●Please sign and date the Authorization to Obtain and Release Information and attach it to the Employee’s Statement. Your signature lets Standard Insurance Company (The Standard) get the information about you that we need to determine your eligibility for beneﬁts. The Authorization to Obtain and Release Information also lets The Standard release this information to speciﬁc persons.

If you have seen or been treated by a Psychiatrist, Psychotherapist, Psychologist, Clinical Social Worker (MSW, MCSW, etc.), or any other provider of treatment for a mental condition, please sign and return the Authorization to Obtain and Release Information and the Authorization to Obtain and Release Psychotherapy Notes.

You will receive copies of these Authorizations upon your request.

3.The Attending Physician’s Statement

●

Part A should be completed by you.

Part B should be completed by your physician. If you have seen more than one physician for your disability, a statement should be completed by each physician. Your physician(s) should mail the completed form directly

to The Standard.

4.The Employer’s Statement

● This form should be completed by your employer, who will mail it to The Standard.

You are responsible for making sure all required forms are completed and returned to our ofﬁce. If you have any questions,

our ofﬁce is here to help you.

SI 3379 CTA

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		Reset
Standard Insurance Company	Return to page 1
Standard Insurance Company
CTA Beneﬁts and Services

	Disability Insurance
PO Box 2773 Portland OR 97208	Disability Insurance
Tel 800.522.0406 Fax 888.414.0390	Employee’s Statement

Please print clearly. Form may be returned for unanswered questions.

1. CLAIMANT

Last Name:

First Name:

Middle Name:

Sufﬁx:

Social Security No.:

Address:

City:

State:

Zip Code:

Phone No.:

Patient No.:

Birthdate:

Gender:  Male

 Female

Height:

Weight:

Spouse/Domestic Partner Information

Last Name:

First Name:

Middle Name:

Sufﬁx:

Date of Birth:

No. of dependent children:

Birthdate of youngest:

Did you receive a Certiﬁcate of Insurance? Yes  No

Did you receive a Brochure?

Yes

 No

If no, please contact The Standard.

2. EMPLOYMENT

School District Name:

Group Policy No.:

Address:

City:

State:

Zip Code:

Phone No.:

Job title:

Describe your Job Duties:

Is your disability work-related?

Yes

 No

Date of injury:

Have you ﬁled a Workers’ Compensation claim?

Yes

 No

If Yes, W.C. claim number:

Last full day at work:

Date you became unable to work at your occupation as a result of disability:

Are you now or have you worked at your occupation or any other occupation since the date of your injury?

Yes

 No

If yes, provide name of employer and

dates of employment:

Employer Name:

Phone No.:

Address:

City:

State:

Zip Code:

Employment Start Date:

Employment End Date:

Are you self-employed at any activity?

Yes

 No

Date you resumed part-time work:

Work

Phone:

Extension:

Date you resumed full-time work:

Work

Phone:

Extension:

SI 3379 CTA

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Standard Insurance Company

CTA Beneﬁts and Services

PO Box 2773 Portland OR 97208

Tel 800.522.0406 Fax 888.414.0390

Disability Insurance Employee’s Statement

Claimant’s Name:

3.SICKNESS Please list all illnesses which contribute to your being unable to work at your occupation.

Illness:

Date First Noticed:

Illness:

Date First Noticed:

State what you believe caused your illness.

Describe your symptoms:

Have you ever had the same condition or a related illness before? Yes

 No

Date:

4. INJURY

Describe Injuries:

Cause of Injuries:

Date injury occurred:

Time injury occurred:

Location where injury occurred:

5. PREGNANCY

Date you expect to cease work:

Expected delivery date:

Actual delivery date:

Expected return to work date:

Please indicate any foreseeable complications.

6. ATTENDING PHYSICIAN List all physicians consulted for this injury or illness. Use separate sheet, if needed.

Physician’s Last Name:

First Name:

Specialty:

Phone No.:

Address:

City:

State:

Zip Code:

Date ﬁrst consulted for this injury or illness:

Date last consulted:

Physician’s Last Name:

First Name:

Specialty:

Phone No.:

Address:

City:

State:

Zip Code:

Date ﬁrst consulted for this injury or illness:

Date last consulted:

Physician’s Last Name:

First Name:

Specialty:

Phone No.:

Address:

City:

State:

Zip Code:

Date ﬁrst consulted for this injury or illness:

Date last consulted:

SI 3379 CTA

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Standard Insurance Company

CTA Beneﬁts and Services

PO Box 2773 Portland OR 97208

Tel 800.522.0406 Fax 888.414.0390

Disability Insurance Employee’s Statement

Claimant’s Name:

7. HOSPITAL If you were hospitalized for this condition, please complete. Please attach copy of hospital bill if available.

Hospital Name:

Address:

City:			State:	Zip Code:
From:	through:	Reason for hospitalization:
From:	through:	Reason for hospitalization:

8. HISTORY List all illnesses or injuries for which you have received treatment over the past ﬁve years. Use separate sheet if needed.

Ailment:

Date of treatment:

Physician’s Last Name:

First Name:

Address:

City:

State:

Zip Code:

Ailment:

Date of treatment:

Physician’s Last Name:

First Name:

Address:

City:

State:

Zip Code:

Ailment:

Date of treatment:

Physician’s Last Name:

First Name:

Address:

City:

State:

Zip Code:

Ailment:

Date of treatment:

Physician’s Last Name:

First Name:

Address:

City:

State:

Zip Code:

Ailment:

Date of treatment:

Physician’s Last Name:

First Name:

Address:

City:

State:

Zip Code:

Ailment:

Date of treatment:

Physician’s Last Name:

First Name:

Address:

City:

State:

Zip Code:

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How to Edit Form Si 3379 Cta Online for Free

Our top level developers have worked collectively to get the PDF editor that you'll apply. This particular software makes it simple to submit CTA forms promptly and efficiently. This is certainly all you need to conduct.

Step 1: You can click the orange "Get Form Now" button at the top of this web page.

Step 2: You can see each of the options that it's possible to use on the template as soon as you've accessed the CTA editing page.

Fill out the CTA PDF by typing in the text needed for each individual section.

Inside the section Standard Insurance Company CTA, Please print clearly Form may be, Disability Insurance Employees, CLAIMANT, Last Name, Middle Name, Address, City, Phone No, Birthdate, First Name, Sufﬁ x, Patient No, Social Security No, and State write down the data which the system asks you to do.

Standard Insurance Company CTA, Please print clearly Form may be, Disability Insurance Employees, CLAIMANT, Last Name, Middle Name, Address, City, Phone No, Birthdate, First Name, Sufﬁ x, Patient No, Social Security No, and State in STRS

The application will require particulars to quickly prepare the part No of dependent children, Birthdate of youngest, Did you receive a Certiﬁ cate of, Did you receive a Brochure Yes No, If no please contact The Standard, EMPLOYMENT, School District Name, Address, City, Phone No, Job title, Describe your Job Duties, Group Policy No, State, and Zip Code.

You'll have to indicate the rights and obligations of each side in field Employer Name, Address, City, Phone No, State, Zip Code, Employment Start Date, Employment End Date, Are you selfemployed at any, Date you resumed parttime work, Date you resumed fulltime work, Work Phone, Work Phone, Extension, and Extension.

STRS Employer Name, Address, City, Phone No, State, Zip Code, Employment Start Date, Employment End Date, Are you selfemployed at any, Date you resumed parttime work, Date you resumed fulltime work, Work Phone, Work Phone, Extension, and Extension fields to fill

Finalize by looking at the next areas and filling them in accordingly: Standard Insurance Company CTA, Claimants Name, SICKNESS Please list all, Illness, Illness, State what you believe caused your, Describe your symptoms, Have you ever had the same, Date, Disability Insurance Employees, Date First Noticed, Date First Noticed, INJURY, Describe Injuries, and Cause of Injuries.

Step 3: As soon as you click the Done button, your finished document can be easily exported to any kind of your gadgets or to email indicated by you.

Step 4: It is easier to prepare copies of the file. You can rest assured that we will not publish or see your details.

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