Notied Details

Form Si 3379 Cta is a form that can be used to calculate the Illinois state income tax. This form is for individuals who are required to file an Illinois return, and it can be used to determine the amount of tax that is owed. The instructions for filling out this form are provided on the second page, and taxpayers should ensure that they understand how to complete the form correctly. There are many factors that need to be considered when calculating state income tax, so it is important to take your time and make sure everything is correct. If you have any questions, you can always contact a tax specialist for assistance.

In the listing, there is some information about the form si 3379 cta. There, you'll locate the details about the form you intend to fill out, such as the estimated time for you to fill it out and other particulars.

QuestionAnswer
Form NameForm Si 3379 Cta
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesRHODE, nes, false, si3379cta

Form Preview Example

Standard Insurance Company

CTA Benefits and Services

 

 

PO Box 2773 Portland OR 97208

 

Disability Insurance

Tel 800.522.0406 Fax 888.414.0390

 

Employer’s Statement

 

 

 

Policy No.:

 

Voluntary Insurance Coverage

District Paid Insurance Coverage

Please print clearly, and complete all questions. Form may be returned for completion of unanswered questions.

1. EMPLOYEE

 

Name of employee:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

Zip Code:

 

 

 

Job Title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Class: Faculty/Teacher

 

Education Support Professional

Administration

Secretarial/Clerical

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone No.: (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Employed:

 

 

 

 

 

 

 

Social Security No.:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last day worked:

 

 

 

 

 

 

 

 

 

 

 

 

 

Number of hours worked on last day:

 

 

 

 

 

 

 

First full day of absence for this disability (mo/da/yr):

 

 

 

Status on day of disability:

Full-time

Part-time 11 or 12 month employee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insured’s premium paid to date:

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you required to make Medicare contributions for this employee? Yes

 

No

 

Are you required to make Social Security contributions for this employee?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has employee retired? Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the employee participate in your formal retirement plan?

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is the employee eligible but not participating in your formal retirement plan? Yes

No

 

Is the formal retirement plan carrier

STRS PERS Other

 

If other, provide name and address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is employment terminated?

Yes No

Date of termination:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reason for termination:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is employment scheduled for termination?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has employee returned to work?

 

Yes

No

 

If yes, Full-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Return date

 

 

 

 

 

 

 

 

 

 

 

 

 

Return date

 

If intermittent absences, please show dates:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was this disability due to occupational cause? Yes No If yes, include name and address of Workers’ Compensation carrier:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Workers’ Compensation carrier Telephone No.:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last day of occupational cause leave:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. SALARY AT TIME OF DISABILITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Salary at start of disability:

 

 

 

 

Hourly:

 

 

 

 

 

 

 

 

 

Monthly:

 

 

 

 

 

 

Annual Contract:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Average number of hours worked: Day:

 

 

 

 

 

 

 

 

 

or Week:

 

 

 

 

 

 

Total days of required attendance this school year:

Daily rate of pay:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First required day of attendance:

 

 

 

 

 

 

 

 

 

 

 

 

Winter vacation starts – and ends:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spring vacation starts – and ends:

 

 

 

 

 

 

 

 

 

 

 

Last required day of attendance:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is school on 12 month schedule?

 

Yes

No

If yes, please attach track schedule.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If part-time, please attach schedule.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If vacation schedule differs from above, please indicate employee’s scheduled vacation.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SI 3379 CTA

DBEMP

1 of 4

%! (8/14)

Standard Insurance Company

CTA Benefits and Services

 

 

 

 

 

 

 

 

 

 

PO Box 2773 Portland OR 97208

 

 

 

 

 

 

 

 

Disability Insurance

Tel 800.522.0406

Fax 888.414.0390

 

 

 

 

 

 

 

Employer’s Statement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Claimant’s Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. COMPENSATION FOR PERIOD AFTER DISABILITY

 

 

 

 

 

 

 

 

Sick Leave days available at start of this disability:

 

 

 

 

 

 

Last day at full pay (mo/da/yr):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

When accumulated sick leave is exhausted, do you pay the difference between monthly contract salary and the total paid to a substitute for the number of work days

in that month?

Yes No

 

 

 

 

 

 

 

 

 

 

If no, please describe method used:

 

 

 

 

 

 

 

 

 

 

 

Number of days at Sub or other pay (if applicable):

 

 

Date Sub deductions start from employee’s pay (mo/da/yr):

 

 

Sub pay rate:

 

 

 

When will Sub rate change? (mo/da/yr)

 

 

 

 

 

 

What amount will it change to?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Salary Continuance or Sub Differential pay ends (mo/da/yr):

 

 

 

Any other pay received from the district?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is the employee eligible for any other income replacement plan? Yes

No

Carrier:

Address and/or Telephone No.:

 

 

 

 

 

 

 

 

 

 

 

Is employee eligible to draw from any other benefits? Yes No

 

 

 

 

 

 

 

 

 

 

If yes, please explain

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Effective date:

 

 

 

 

 

No. of days:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. EXTRA DUTY PAY

*Extra Duty Pay includes, but is not limited to, income received from coaching, after-school programs, summer school sessions, advising or mentoring stipends. Extra duty pay must be defined in a special contract or letter of agreement between the insured and the district. It does not include additional compensation such as overtime pay, bonuses or district-funded fringe benefits.

Attach a copy of the agreement and the work schedule.

Begin date:

 

End date:

Please indicate dates this pay was NOT PAID due to the employee’s disability:

Applicable rate of pay NOT PAID due to disability.

Hourly rate:Number of hours per day:Daily rate:Weekly rate:Monthly rate:

6. LIFE INSURANCE

Was employee covered by Group Life Insurance with The Standard on cease work date? Yes No

If yes, list policy number(s):

Date life insurance became effective:

 

 

 

 

 

Please attach Enrollment form(s), if applicable.

Amount of Basic life insurance $

 

 

 

Additional/Optional $

Supplemental $

 

AD&D $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dependent’s coverage? Yes

No

 

 

 

 

 

 

 

 

IMPORTANT: Please continue payment of premiums until otherwise notified.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. TAX INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

Does this employee pay all or a portion of the premium for Disability Benefits insurance coverage?

Yes

No

*If yes, what percentage of the Disability Benefits premium does the employer pay

 

 

%.

 

 

 

 

 

 

 

 

 

 

*the employee pay

 

 

% with “pre-tax” funds.

 

 

 

 

*the employee pay

 

 

% with funds that have been taxed.

* If yes, are employer paid premiums included in the employee’s salary? Yes No

 

 

 

 

 

 

*IMPORTANT: Remember to calculate the premium contribution percentage information according to the IRS Group Policy (three year averaging) rule.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SI 3379 CTA

2 of 4

(8/14)

Standard Insurance Company

CTA Benefits and Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PO Box 2773 Portland OR 97208

 

 

 

 

 

 

 

 

 

 

 

 

 

Disability Insurance

Tel 800.522.0406

Fax 888.414.0390

 

 

 

 

 

 

 

 

 

 

 

 

Employer’s Statement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Claimant’s Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. ATTACHMENTS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please attach copies of the following.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Job Description

c. Income From Other Sources (Deductible Benefits) Documents

 

 

d. Enrollment form(s), if applicable

b. Employment Application or Resume

(Social Security, Worker’s Compensation, PERS, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. SCHOOL DISTRICT REPRESENTATIVE COMPLETING THIS FORM

 

 

 

 

 

 

 

 

 

 

 

Employer/School District Name:

 

 

 

 

Phone No.:

 

 

 

 

 

 

Policy Number:

 

 

Address:

 

 

 

 

 

 

City:

 

 

State:

 

 

 

Zip Code:

 

 

Acknowledgement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I hereby certify that the answers I have made to the foregoing questions are both complete and true to the best of my knowledge and belief.

I acknowledge that I have read the applicable fraud notice on page 4 of this form.

 

 

 

 

 

 

 

 

 

 

 

Signature:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

 

 

Prepared by:

 

 

 

 

 

 

 

 

Title:

 

 

 

 

 

 

 

 

 

 

 

 

Phone No.: (

)

 

 

 

 

 

Fax No.: (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SI 3379 CTA

3 of 4

(8/14)

Standard Insurance Company

CTA Benefits and Services

 

PO Box 2773 Portland OR 97208

Disability Insurance

Tel 800.522.0406 Fax 888.414.0390

Claim Form Fraud Notices

 

Some states require us to provide the following information to you:

ALABAMA, MARYLAND AND RHODE ISLAND RESIDENTS

Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

CALIFORNIA RESIDENTS

For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

COLORADO RESIDENTS

It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to the policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

DISTRICT OF COLUMBIA RESIDENTS

WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant.

FLORIDA RESIDENTS

Any person who knowingly and with intent to injure, defraud or deceive an insurance company, files a statement of claim or an application containing false, incomplete or misleading information is guilty of a felony of the third degree

NEW JERSEY RESIDENTS

Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

NEW YORK RESIDENTS

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 civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

PENNSYLVANIA RESIDENTS

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 subjects such person to criminal and civil penalties.

ALL OTHER RESIDENTS

Some states require us to inform you that any person who knowingly and with intent to injure, defraud or deceive an insurance company, or other person, files a statement containing false or misleading information concerning any fact material hereto commits a fraudulent insurance act which is subject to civil and/or criminal penalties, depending upon the state. Such actions may be deemed a felony and substantial fines may be imposed.

SI 3379 CTA

4 of 4

(8/14)

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 .