Question	Answer
Form Name	Long Term Disability Form
Form Length	13 pages
Fillable?	Yes
Fillable fields	380
Avg. time to fill out	39 min 37 sec
Other names	long disability form, metlife long term disability forms, how to fill out a claim for a long term disability form fo a cancelled policy, long term disability form ontario pdf

First and Last Name of any children under the age of 25	Date of Birth
____________________________________________________________________________________	___________________________
____________________________________________________________________________________	___________________________
____________________________________________________________________________________	___________________________

Why are you unable to work?
Before you stopped working, did your condition require you to change your job or the way you did your job? n Yes						n No If Yes, please explain below.
Is your condition related to your occupation? n Yes	n No If Yes, please explain below.
Have you filed, or do you intend to file a Workers’ Compensation claim? n Yes					n No

D. Information About Work
What is the date of your last day worked before the disability?		On your last day worked, did you work a full day?
		n Yes		n No	If No, please explain.

What is the date you were first unable to work?			Have you returned to work? n Yes, Part-Time			n Yes, Full-Time n No
			What date did you return to work?

If you haven’t yet returned to work, do you expect to?	n Yes, Part-Time			n Yes, Full-Time n No
What date do you expect to be able to return to work?


EMPLOYEE: ________________________________________________________________		Page 2 of 10
FAX NUMBER (402) 997-1865	Form must be completed in full at no expense to Mutual of Omaha

Doctor who first provided medical attention to you for your current disability.	Doctor’s Specialty		Telephone (	)
			Fax (	)

Doctor’s Address		Date(s) you were seen by this doctor
		From ____________ To ____________

Have you ever had the same or a similar condition in the past? n Yes	n No If Yes, provide the following information concerning past treatments.

Doctor’s Name		Doctor’s Specialty		Telephone (	)
				Fax (	)

Doctor’s Address			Date(s) you were seen by this doctor
			From ____________ To ____________

Name of Hospital		Department of Treatment		Telephone (	)
				Fax (	)

Hospital’s Address			Date(s) you were treated at the hospital
			From ____________ To ____________

Source of Income	Amount	Weekly/	Date claim was filed	Date payments began	Date payments ended
		Monthly
Social Security Retirement	___________	____________	_________________	__________________	_________________
Social Security Disability	___________	____________	_________________	__________________	_________________
Canadian Pension Plan	___________	____________	_________________	__________________	_________________
Workers’ Compensation	___________	____________	_________________	__________________	_________________
State Disability	___________	____________	_________________	__________________	_________________
Pension Retirement	___________	____________	_________________	__________________	_________________
Pension Disability	___________	____________	_________________	__________________	_________________
Short-Term Disability	___________	____________	_________________	__________________	_________________
Unemployment	___________	____________	_________________	__________________	_________________
No-Fault Insurance	___________	____________	_________________	__________________	_________________
Other (include Individual or Group benefits) ___________		____________	_________________	__________________	_________________

EMPLOYEE: ________________________________________________________________					Page 3 of 10
FAX NUMBER (402) 997-1865				Form must be completed in full at no expense to Mutual of Omaha

Education, Training and Work Experience
Name_________________________________________________________________________________________________________________________________
Policy No. ______________________________________________________				Claim No. _______________________________________________

Educational Background
High School Graduate	n Yes	n No	If No, what was the last grade completed? ________________ Last date attended ________________
GED n Yes n No	Field of Study n General n Business n Vocational			n Other
Did you attend college? n Yes		n No	Last Date Attended ________________

Company’s Address (Number, Street, City, State, ZIP)		Company’s Telephone (		)
		Company’s Fax (		)

Name and Address of Location Where Employee Works	Location No.	Location Telephone (		)
		Location Fax (	)

Employee’s Hire Date	Date Employee became insured under this plan: __________________	No. of hours Employee regularly works per day/per week?

	Date Employee became insured under prior plan: _________________	______ # of hours per/week ______ # of hours per/day

Is Employee covered under a Group Life policy with United of Omaha? n Yes	n No If Yes, what is the effective date of the life insurance plan?

What is Employee’s annual salary?	Amount of Life insurance as of last day worked

If Yes, please answer the following questions.	Weekly amount?	Date benefits begin?	Date benefits end?

Is Employee eligible for Salary Continuation?	n Yes n No If Yes, please answer the following questions.
Weekly amount?	Date benefits begin?	Date benefits end?


EMPLOYEE: ________________________________________________________________		Page 4 of 10
FAX NUMBER (402) 997-1865	Form must be completed in full at no expense to Mutual of Omaha

_______________________________________________________________	________________
Signature of Claimant	Date


EMPLOYEE: ________________________________________________________________		Page 6 of 10
FAX NUMBER (402) 997-1865	Form must be completed in full at no expense to Mutual of Omaha

What was Employee’s permanent job on his/her last day worked?			How long had Employee been in this job?

Why did Employee stop working?			Has Employee returned to work? n Yes n No
			If Yes, when?

Is Employee’s condition work related? n Yes n No		Has a Workers’ Compensation claim been filed? n Yes n No
		If Yes, send initial report of illness/injury and award notice.

Name of Workers’ Comp Carrier	Address of Workers’ Comp Carrier			Contact Person’s Name & Phone No.


EMPLOYEE: ________________________________________________________________		Page 7 of 10
FAX NUMBER (402) 997-1865	Form must be completed in full at no expense to Mutual of Omaha

n No If Yes, please answer the following questions.
Date benefits begin?	Date benefits end?

Indicate how each of the following related to Employee’s job.
	Occasionally (0%-33%)	Frequently (34%-66%)	Continuously (67%-100%)
Computer use	____________	____________	____________
Relate to others	____________	____________	____________
Written and verbal communication	____________	____________	____________
Reasoning, math and language	____________	____________	____________
Make independent judgments	____________	____________	____________

Which of the following describe Employee’s working environment? Check all that apply.
n Unprotected heights	n Changes in temperature	n Exposure to dust, fumes and gases
n Being near moving machinery	n Driving automotive equipment	n Other hazards (please explain)

Is Employee required to travel? n Yes n No	If Yes, please answer the following questions.
How does Employee travel? n Automobile	n Plane n Train n Other

Long Term Disability Form – Fill Out and Use This PDF

Long Term Disability Form PDF Details