A long term disability form is a document that provides information about an individual's long term disability. This form can be used to apply for benefits, to report changes in status, or to request reconsideration of a claim. The long term disability form can be used to provide accurate and up-to-date information about an individual's disability. Understanding the information on this form can help submit a complete and accurate application for benefits.
Here is the data concerning the PDF you were looking for to fill out. It can show you just how long it will take to fill out long term disability form, exactly what fields you need to fill in and several additional specific details.
| Question | Answer |
|---|---|
| Form Name | Long Term Disability Form |
| Form Length | 13 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 3 min 15 sec |
| Other names | long term disability form manulife, form long term disability, prudential long term disability application form, long term disability form on line nj |
A Guide for Successfully Completing the
Group
Mutual of Omaha appreciates the opportunity to provide you with valuable income protection. We rely on the information you provide on this form to effectively determine if you qualify for group
This guide provides information and instruction to help you successfully complete and submit the claim form. Please consult your employer/benefits administrator if you need assistance in providing information for the form.
IMPORTANT TIPS FOR PAPER COPY SUBMISSION
nPrior to submission, make sure all required information is provided and all questions have been answered completely and accurately. If information is missing or is illegible (unreadable), the processing of your form will be delayed.
nRefer to the guidelines for each section below, which provide valuable information to help you successfully complete the form.
nMake a copy of the completed form for your records before submitting it to Mutual of Omaha/United of Omaha.
GUIDELINES FOR SECTION 1: EMPLOYEE’S STATEMENT
This section is to be completed by the Employee. Please answer all questions in order to avoid possible delays. All dates should indicate the month, date and year.
A. Information About You
nThe Group Policy Number will have eight characters, beginning with “G000” followed by four additional letters or numbers specific to your employer.
nProvide weight in pounds, and height in feet and inches.
nYour Occupation/Job Title is the title of your position held with the employer.
nIndicate any other Mutual of Omaha/United of Omaha plans in which you are currently insured.
C. Information About Your Disabling Condition
nThe Date First Treated is the date you first sought out medical care because of the disabling condition.
D. Information About Work
nThe Last Day Worked is the day before you were first absent from work because of the disabling condition.
E. Information About Care and Treatment
nProvide the name, specialty, phone and address for each doctor or hospital that treated you for the disabling condition.
F. Information About Other Income Benefits
nOther Income means money you are currently receiving or have applied to receive from any source in addition to your claim for disability benefits with Mutual of Omaha/ United of Omaha.
nCheck all sources of other income that apply.
G. Information For Tax Withholding
nIf your claim is paid, indicate whether or not you would like Mutual of Omaha to withhold income tax from your benefit payment, and if so, how much. Minimum is $88 per month.
H. Signature
nYour signature is required.
EDUCATION, TRAINING AND WORK EXPERIENCE
nThis form is to be completed by the employee. Please make sure all questions have been answered completely and accurately. If information is missing or is illegible (unreadable), the processing of your form will be delayed.
nVocational rehabilitation services include, but are not limited to (a) job modification; (b) job placement;
(c) retraining; and (d) other activities reasonably necessary to help you return to work.
AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION
This authorization is to be completed by the employee.
nPlease read this section in its entirety. By signing the authorization, you are applying for
nIf the name associated with any of your medical records differs from the name provided on the form, provide any alternate names. This might occur in the event of a name change due to marriage or adoption, for example.
nIMPORTANT: To be complete, the form must be signed by you.
GUIDELINES FOR SECTION 2: EMPLOYER’S STATEMENT
This section is to be completed by the employer. Please answer all questions in order to avoid possible delays. All dates should indicate the month, date and year.
A. Information About the Employer
nThe Group Policy Number will have eight characters, beginning with “G000” followed by four additional letters or numbers.
B. Information About the Employee
nThe Date Employee Became Insured Under This Plan indicates the date in which the employee’s coverage became effective.
nThe Date Employee Became Insured Under Prior Plan indicates the date in which the employee’s coverage was in effect under a plan prior to the Mutual of Omaha plan.
nThe No. of Hours Employee Regularly Works is the number of hours the employee is typically at work per day/per week for the employer.
MUG1710A_0212 |
LTD Claim Form Guide_1009 |
C. Information For Tax Withholding
nIf this section is not completed, Mutual of Omaha will assume that premium paid by the employee is with
nIf this is not true, indicate otherwise and provide the percentage amount.
E. Information For Life Waiver
nDate Life Insurance Terminated means the first day the coverage is no longer in force.
nIf applicable, the Paid To Date for group life insurance is the date on which the next premium is due.
F. Information About Your Pension Plan
nThis section is not applicable if the disabling condition is maternity.
H. Information About Employee’s Salary
nIndicate the method in which the employee is paid.
nIf hourly, also indicate the hourly rate in which the employee is paid.
nPlease attach supporting payroll documentation.
GUIDELINES FOR SECTION 3: JOB ANALYSIS
This section is to be completed by the employer. Please answer all questions in order to avoid possible delays. All dates should indicate the month, date and year.
A. Information About the Employee’s Job
nOccasionally means the employee does this activity up to 33 percent of the time.
nFrequently means the employee does the activity 34 percent to 66 percent of the time.
nContinuously means the employee does the activity 67 percent to 100 percent of the time.
B. Physical Aspects of the Job
nCheck all the activities that apply to the employee’s job.
nIndicate the frequency with which the employee performs the activity using the guidelines in Section A. Information About the Employee’s Job.
GUIDELINES FOR SECTION 4: SIGNATURE AND ATTACHMENTS
nAttach a copy of the employee’s job description to the claim application.
nAttach any additional documentation that may be helpful when reviewing the application, including further explanation of any question(s) on the application.
nYour signature is required.
GUIDELINES FOR SECTION 5: PHYSICIAN’S STATEMENT
This section is to be completed by the attending physician. Please answer all questions in order to avoid possible delays. All dates should indicate the month, date and year.
REQUIRED FRAUD WARNINGS
Before completing the claim form, please read the Required Fraud Warnings listed on the following page.
MUG1710A_0212 |
LTD Claim Form Guide_1009 |
REQUIRED FRAUD WARNINGS (STATE SPECIfiC WARNINGS APPLY TO THE RESIDENT OF SUCH STATE)
nFraud Warning: 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.
nAlabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject
to restitution fines or confinement in prison, or any combination thereof.
nArkansas/Kentucky/Louisiana/Maine/New Mexico/ Ohio/Tennessee: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
nCalifornia: 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.
nColorado: 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 a 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.
nDistrict of Columbia: 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.
nKansas: 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 as determined by a court of law.
nMaryland: 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.
nNew Jersey: Any person who includes any false or misleading information on an application for insurance is subject to criminal and civil penalties.
nNew York: 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 a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
nOregon: 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 may be a crime and may subject such person to criminal and civil penalties.
nPuerto Rico: Any person who furnishes information verbally or in writing, or offers any testimony on improper or illegal actions which, due to their nature constitute fraudulent acts in the insurance business, knowing that the facts are false shall incur a felony and, upon conviction, shall be punished by a fine of not less than five thousand (5,000) dollars, nor more than ten thousand (10,000) dollars for each violation or by imprisonment for a fixed term of three (3) years, or both penalties. Should aggravating circumstances be present, the fixed penalty thus established may be increased to a maximum of five (5) years; if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.
nRhode Island: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information on an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
nVermont: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claims containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto may be committing a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties.
nVirginia: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law.
Mutual of Omaha Insurance Company
United of Omaha Life Insurance Company
Group Insurance Claims Management
Mutual of Omaha Plaza |
|
Omaha, NE |
|
Phone |
Fax |
Section 1 – Employee’s Statement (Answer all questions to avoid delay.)
A. Information About You
Last Name
First Name
Middle Initial
Group Policy Number
Address
City
State/Province
ZIP
Telephone ( )
Email Address
Social Security Number
Date of Birth
Height
Weight
nMale
nFemale
n Right Handed n Left Handed
nSingle
nMarried
nWidowed
nDivorced
Name of Your Employer (include Division/Location, if applicable)
Your Occupation/Job Title
Under what other Mutual of Omaha/United of Omaha policies are you currently covered?
Important Notice: If you are age 60 or over, please contact your employer within 31 days of disability to preserve your group life insurance conversion privileges.
If your coverage is written in California, North Carolina or Michigan and includes Survivor Benefits, please check your policy to determine if you can elect a survivor benefit beneficiary. If so, you may obtain a Beneficiary Designation form on the Internet or from your employer.
B. Information About Your Family (Required to determine your eligibility for Social Security benefits.)
Spouse’s Name
Spouse’s Social Security Number
Spouse’s Date of Birth
Is your spouse employed?
nYes
nNo
First and Last Name of any children under the age of 25 |
Date of Birth |
____________________________________________________________________________________ |
___________________________ |
____________________________________________________________________________________ |
___________________________ |
____________________________________________________________________________________ |
___________________________ |
C.Information About Your Disabling Condition
1.If your disability is due to an injury, answer the following questions and then proceed to #3 below.
When did the injury occur?
Where and how did the injury occur?
What is the date you were first treated by a physician?
2. If your disability is due to a pregnancy or an illness, answer the following questions. If not
What were your first symptoms?
When did you notice these symptoms?
What is the date you were first treated by a physician?
3. If your disability is due to an injury or an illness, but not pregnancy, answer the following questions.
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, |
n Yes, |
||
|
|
|
What date did you return to work? |
|
||
|
|
|
|
|
|
|
If you haven’t yet returned to work, do you expect to? |
n Yes, |
n Yes, |
|
|||
What date do you expect to be able to return to work? |
|
|
|
|
|
|
|
|
|
|
|
|
|
Are you currently
nYes
n No If Yes, provide details.
MUG1710A_0212 |
Page 1 of 10 |
Form continued on Page 2 |
EMPLOYEE: ________________________________________________________________ |
Page 2 of 10 |
|
FAX NUMBER (402) |
Form must be completed in full at no expense to Mutual of Omaha |
|
E. Information About Care and Treatment (If additional space is needed, please provide details on a separate page.)
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 ____________ |
||
|
|
|
|
|
List all other physicians and/or hospitals you have visited for this condition below.
Doctor’s Name
Doctor’s Address
Doctor’s Name
Doctor’s Address
Name of Hospital
Hospital’s Address
Doctor’s Specialty |
|
Telephone ( |
) |
|
|
Fax ( |
) |
|
|
|
|
|
Date(s) you were seen by this doctor |
||
|
From ____________ To ____________ |
||
Doctor’s Specialty |
|
Telephone ( |
) |
|
|||
|
|
Fax ( |
) |
|
|
|
|
|
Date(s) you were seen by this doctor |
||
|
From ____________ To ____________ |
||
Department of Treatment |
|
Telephone ( |
) |
|
|||
|
|
Fax ( |
) |
|
|
|
|
|
Date(s) you were treated at the hospital |
||
|
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 ____________ |
||
|
|
|
|
|
|
F. Information About Other Income Benefits (Check all benefits you are receiving or are eligible to receive.)
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 |
___________ |
____________ |
_________________ |
__________________ |
_________________ |
___________ |
____________ |
_________________ |
__________________ |
_________________ |
|
Unemployment |
___________ |
____________ |
_________________ |
__________________ |
_________________ |
___________ |
____________ |
_________________ |
__________________ |
_________________ |
|
Other (include Individual or Group benefits) ___________ |
____________ |
_________________ |
__________________ |
_________________ |
|
G. Information For Tax Withholding
If your request for benefits is approved, should Mutual of Omaha/United of Omaha withhold income taxes from your benefit checks? If yes, how much should be withheld from each check (the minimum is $88.00 per month). $____________.00
nYes
nNo
Overpayment Notice: Should you become overpaid at anytime during the duration of this claim we, Mutual of Omaha Insurance Company (Mutual) or United of Omaha Life Insurance Company (United), will request reimbursement of the overpaid amount. This amount is equal to the net benefit you received and any Federal Income Tax paid on your behalf for any time prior to current tax year. Your signature on the claim form authorizes Mutual or United to recover any overpaid Medicare and/or Social Security Tax that was paid on your behalf and certifies you will not attempt to recover a refund or credit of the Medicare and/or Social Security Tax with any Form
H. Signature (Required for all claims.)
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
The above statements are true and complete to the best of my knowledge and belief.
X ____________________________________________________ |
_________________________ |
|
|
Signature of Employee |
Date |
MUG1710A_0212 |
Page 2 of 10 |
Form continued on Page 3 |
EMPLOYEE: ________________________________________________________________ |
Page 3 of 10 |
||||
FAX NUMBER (402) |
|
|
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 ________________ |
|
|
|
Name and Address of College: ___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Major(s): ______________________________________________________________________________________________________________________________
Final Status: n Freshman n Sophomore n Junior n Senior n Undergraduate Degree n Graduate School
Degree(s) earned: ______________________________________________________________________________________________________________________
Other formal training: ___________________________________________________________________________________________________________________
Certification(s):_________________________________________________________________________________________________________________________
Computer Skills: ________________________________________________________________________________________________________________________
Military Service n Yes n No If Yes, in which branch did you serve? __________________________________________________________________________
Rank: _________________________________________________________________________________________________________________________________
Specialty: _____________________________________________________________________________________________________________________________
What computer programs are you able to use?_______________________________________________________________________________________________
List all languages spoken fluently: _________________________________________________________________________________________________________
Work Experience
Please fill out completely. Start with your most recent employment and list chronologically.
Dates: From ___________________ To ___________________
Employer: _____________________________________________________________________________________________________________________________
Job Title: ______________________________________________________________________________________________________________________________
List job duties: _________________________________________________________________________________________________________________________
List physical requirements of job: _________________________________________________________________________________________________________
Product/service produced: _______________________________________________________________________________________________________________
Did you supervise others? n Yes n No
Reason for leaving? _____________________________________________________________________________________________________________________
Dates: From ___________________ To ___________________
Employer: _____________________________________________________________________________________________________________________________
Job Title: ______________________________________________________________________________________________________________________________
List job duties: _________________________________________________________________________________________________________________________
List physical requirements of job: _________________________________________________________________________________________________________
Product/service produced: _______________________________________________________________________________________________________________
Did you supervise others? n Yes n No
Reason for leaving? _____________________________________________________________________________________________________________________
MUG1710A_0212 |
Page 3 of 10 |
Form continued on Page 4 |
EMPLOYEE: ________________________________________________________________ |
Page 4 of 10 |
|
FAX NUMBER (402) |
Form must be completed in full at no expense to Mutual of Omaha |
|
Dates: From ___________________ To ___________________
Employer: _____________________________________________________________________________________________________________________________
Job Title: ______________________________________________________________________________________________________________________________
List job duties: _________________________________________________________________________________________________________________________
List physical requirements of job: _________________________________________________________________________________________________________
Product/service produced: _______________________________________________________________________________________________________________
Did you supervise others? n Yes n No
Reason for leaving? _____________________________________________________________________________________________________________________
Dates: From ___________________ To ___________________
Employer: _____________________________________________________________________________________________________________________________
Job Title: ______________________________________________________________________________________________________________________________
List job duties: _________________________________________________________________________________________________________________________
List physical requirements of job: _________________________________________________________________________________________________________
Product/service produced: _______________________________________________________________________________________________________________
Did you supervise others? n Yes n No
Reason for leaving? _____________________________________________________________________________________________________________________
Dates: From ___________________ To ___________________
Employer: _____________________________________________________________________________________________________________________________
Job Title: ______________________________________________________________________________________________________________________________
List job duties: _________________________________________________________________________________________________________________________
List physical requirements of job: _________________________________________________________________________________________________________
Product/service produced: _______________________________________________________________________________________________________________
Did you supervise others? n Yes n No
Reason for leaving? _____________________________________________________________________________________________________________________
Additional courses taken, hobbies and special skills. Please be specific such as computer skills either personal or professional, sales, carpentry, auto repair, etc.
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
Are you currently involved in a vocational rehabilitation program? n Yes n No
If yes, please provide the name, address and phone # of the rehabilitation case worker ___________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
Are you interested in learning about our vocational rehabilitation program? n Yes n No
What is your employment goal or other work that you would be interested in doing? _______________________________________________________________
Date: ______________________________ Signature: _________________________________________________________________________________________
MUG1710A_0212 |
Page 4 of 10 |
Form continued on Page 5 |
AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION
1.I authorize any physician, medical or dental practitioner, hospital, clinic, pharmacy benefit manager, other medical care facility, health maintenance organization, insurer, employer, consumer reporting agency and any other provider of medical or dental services to release records containing the personal information of:
Claimant/Patient Name: __________________________________________________________
(Last) |
(First) |
(Middle) |
2.Personal information includes medical history, mental and physical condition, prescription drug records, alcohol or drug use, financial and occupational information.
3.You may release information to:
Group Disability Management Services
Mutual of Omaha Insurance Company/United of Omaha Life Insurance Company
Mutual of Omaha Plaza
Omaha, NE
or
Fax
4.I understand that the personal information that is disclosed will be used by Mutual of Omaha Insurance Company and United of Omaha Life Insurance Company to evaluate my claim for disability benefit plan reimbursement and that if I refuse to sign this authorization my claim for benefits may not be paid.
5.I understand that if the person or entity to whom information is disclosed is not a health care provider or health plan subject to federal privacy regulations, the personal information may be redisclosed without the protection of the federal privacy regulations.
6.This authorization will expire 24 months after the date signed.
7.I understand that I may revoke this authorization at any time by providing a written request to Mutual of Omaha Insurance Company and United of Omaha Life Insurance Company at the address above. If I revoke this authorization, it will not affect any use or disclose of personal information that occurred prior to the receipt of my revocation.
8.I understand that I am entitled to receive a copy of this authorization and that a copy is as valid as the original.
RETAIN A SIGNED COPY FOR YOUR RECORDS
Name(s) used for records (if different than the name below): ________________________________
________________________________________________________________________________
_______________________________________________________________ |
________________ |
Signature of Claimant |
Date |
If Applicable: I am the legal representative of the claimant and I am authorized to grant permission on behalf of the claimant.
Printed Name of Legal Representative:_______________________________________________
Signature of Legal Representative: __________________________________________________
Type of Legal Representative: ______________________________________________________
THIS AUTHORIZATION COMPLIES WITH HIPAA AND OTHER FEDERAL AND STATE LAWS
MUG2854_0212
MUG1710A_0212 |
Page 5 of 10 |
Form continued on Page 6 |
EMPLOYEE: ________________________________________________________________ |
Page 6 of 10 |
|
FAX NUMBER (402) |
Form must be completed in full at no expense to Mutual of Omaha |
|
Section 2 – Employer’s Statement (Answer all questions to avoid delay.)
Employee’s Name
Social Security Number
Date of Birth
Employee’s Address
Employee’s Phone Number
A. Information About the Employer
Company’s Name
Group Policy Number
Class No. or Description
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 ( |
) |
|
|
|
|
|
|
B. Information About Employee
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 |
|
|
|
C. Information For Tax Withholding
If this section is left blank, we will calculate FICA taxes based on the following assumption: 100% Employer contribution or any portion paid by Employee is paid with
Does Employee contribute
nYes
n No If Yes, what percent is paid by Employee? ______%
D. Information About the Claim
Before Employee became fully disabled, were changes made to Employee’s job responsibilities due to the disabling condition?
nYes
nNo
If yes, please describe the changes and when they were made.
Date Employee Last Worked
Did Employee work a full day?
nYes
n No If No, how many hours were worked?
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. |
|
|
|
|
|
|
|
Name and Address of Medical Insurance Carrier
Is Employee covered under a Group Life policy with Mutual of Omaha? n Yes n No
E. Information For Life Waiver
Important Notice: If an Employee is age 60 or over, please refer to the policy provisions regarding group life continuation and conversion rights.
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 |
|
|
Master Policy Number
Class
Location
Date Life insurance terminated?
If not terminated, what is the “paid to date”?
Name of beneficiary (per your records)?
Relationship to Employee?
MUG1710A_0212 |
Page 6 of 10 |
Form continued on Page 7 |
EMPLOYEE: ________________________________________________________________ |
Page 7 of 10 |
|
FAX NUMBER (402) |
Form must be completed in full at no expense to Mutual of Omaha |
|
F. Information About Your Pension Plan (Do not complete for maternity.)
Do you have a pension plan?
nYes
nNo
If Yes, what type?
n Defined Benefit
n Defined Contribution
n401(k)
nProfit Sharing
n Other (specify)
Is Employee eligible for your pension plan?
nYes
nNo
If eligible, does Employee participate? n Yes n No
If Yes, when is Employee eligible for benefits under the pension plan?
If Employee is eligible but does not participate, explain why.
G. Information About Your Rehire or Return to Work Policies
Does your company have a rehire or return to work policy for disabled Employees?
nYes
nNo
Who should we contact if we identify a rehabilitation or return to work option? Name/Title: Contact No.
H.Information About Employee’s Salary (Please attach supporting payroll documentation.)
(Check all that apply) Employee
n is paid hourly ($ |
hourly rate) |
n is salaried
n receives commissions
n receives bonuses
Will Employee file for disability benefits provided by any Employer/Employee Labor Management, State Disability or Union Welfare plan? n Yes n No
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? |
|
|
|
|
|
Is Employee eligible for Sick Leave? Weekly amount?
nYes
n No If Yes, please answer the following questions. |
|
Date benefits begin? |
Date benefits end? |
Per the definition of Basic Monthly Earnings in your Policy, what are Employee’s
Section 3 – Job Analysis (To be completed by the Employee’s Supervisor or HR Department. Answer all questions to avoid delay.)
A. Information About Employee’s Job
Job Title
Minimum education or training required?
How long will Employee’s job be held open?
Does Employee perform supervisory functions?
nYes
n No If Yes, how many people are supervised?
Describe Employee’s job duties.
Indicate how each of the following related to Employee’s job. |
|
|
|
|
Occasionally |
Frequently |
Continuously |
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 |
|
What percent of the time does Employee travel?
Where does Employee travel?
MUG1710A_0212 |
Page 7 of 10 |
Form continued on Page 8 |
EMPLOYEE: ________________________________________________________________ |
Page 8 of 10 |
|
FAX NUMBER (402) |
Form must be completed in full at no expense to Mutual of Omaha |
|
B. Physical Aspects of the Job
Select how each of the following relates to Employee’s job.
|
|
Frequency of Occurrence |
|
Activity |
Occasionally |
Frequently |
Continuously |
|
|||
n Standing |
___________ |
____________ |
___________ |
n Walking |
___________ |
____________ |
___________ |
n Sitting |
___________ |
____________ |
___________ |
n Balancing |
___________ |
____________ |
___________ |
n Stooping |
___________ |
____________ |
___________ |
n Kneeling |
___________ |
____________ |
___________ |
n Crouching |
___________ |
____________ |
___________ |
n Crawling |
___________ |
____________ |
___________ |
n Reaching/working overhead |
___________ |
____________ |
___________ |
n Climbing |
___________ |
____________ |
___________ |
n Number of stairs _____ |
___________ |
____________ |
___________ |
n Height of ladder _____ |
___________ |
____________ |
___________ |
n Pushing |
___________ |
____________ |
___________ |
n Pulling |
___________ |
____________ |
___________ |
n Lifting/Carrying |
___________ |
____________ |
___________ |
Please indicate any activities that require lifting, carrying, pushing or pulling. In addition, specify the weight involved with this activity.
Describe Activity |
Weight |
_______________________________________ |
_________ |
_______________________________________ |
_________ |
_______________________________________ |
_________ |
_______________________________________ |
_________ |
_______________________________________ |
_________ |
_______________________________________ |
_________ |
_______________________________________ |
_________ |
_______________________________________ |
_________ |
_______________________________________ |
_________ |
Can alternating sitting and standing activity help |
Does the job require use of the feet to operate foot controls? n Yes |
n No |
|
Employee perform the job? n Yes n No |
If Yes, list type of equipment. |
|
|
|
|
|
|
How important is good vision in the job? |
|
|
|
|
|
|
|
List the major tasks which require the use of one or both hands. |
One Hand |
Both Hands |
|
________________________________________________________________________ |
____________ |
____________ |
|
________________________________________________________________________ |
____________ |
____________ |
|
________________________________________________________________________ |
____________ |
____________ |
|
Can the job be modified to accommodate the disability either temporarily or permanently? n Yes n No If Yes, explain.
Is it possible to offer Employee assistance in doing the job (e.g., use of technology or personal assistance)? n Yes n No If Yes, explain.
Section 4 – Employer’s Signature and Attachments
(Please Attach Employee’s job description and additional documentation.)
Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing false, incomplete, or misleading information is guilty of a felony of the third degree.
Name of person completing this form: _____________________________________________________________________________________________________
Title: __________________________________________________________ |
Email Address: ____________________________________________________ |
|||
( |
) |
( |
) |
|
Telephone: _____________________________________________________ |
Fax: _____________________________________________________________ |
|||
Signature: ___________________________________________________________________________ |
Date: _______________________________________ |
|||
MUG1710A_0212 |
Page 8 of 10 |
Form continued on Page 9 |
EMPLOYEE: ________________________________________________________________ |
Page 9 of 10 |
|
FAX NUMBER (402) |
Form must be completed in full at no expense to Mutual of Omaha |
|
Section 5 – Physician’s Statement (Answer all questions to avoid delay.)
A. General Information
Patient’s Name
Employer’s Name
Policy Number
Patient’s Social Security Number
Height
Weight
Blood Pressure
Date of Birth
B. Complete the following for normal pregnancy, then go to Section E.
Date of the patient’s last menstrual period?
Expected date of delivery?
Expected length of postpartum recovery?
First date of treatment?
Last date of treatment?
C. Complete the following for all conditions except normal pregnancy.
Primary diagnosis (including
Symptoms
What diagnostic testing has been done?
Objective Findings
Are there secondary conditions contributing to the patient’s disability? If Yes, what are they (include
nYes
nNo
If this is a cardiac condition, what is the functional capacity (American Heart Association)?
n Ejection Fraction n Class |
n Class |
|
|
If this is a psychiatric condition, what is the current GAF score? |
In the past year, what was the patient’s highest GAF score? |
|
|
When did symptoms first appear?
Date of patient’s first visit?
Date patient was first unable to work?
Date of patient’s last visit?
How often do you see this patient?
Is the patient’s condition work related?
nYes
n No If Yes, please explain.
Has patient undergone surgery or expected to have surgery in the future? n Yes n No |
If Yes, answer the following. |
|
Date of surgery: |
Surgical Procedure? |
Result: |
|
|
|
What medication is the patient currently taking or been prescribed? |
|
|
Please indicate other types and frequencies of treatment.
Has the patient been referred to a medical rehabilitation or therapy program?
nYes
n No If Yes, give details.
Have you referred the patient for other types of consultations?
nYes
n No If Yes, give details.
Has the patient been hospital confined? Name of Hospital
nYes
n No If Yes, please complete the following. |
|
Address of Hospital |
Dates of Confinement |
|
From____________ To____________ |
MUG1710A_0212 |
Page 9 of 10 |
Form continued on Page 10 |
EMPLOYEE: ________________________________________________________________ |
Page 10 of 10 |
|
FAX NUMBER (402) |
Form must be completed in full at no expense to Mutual of Omaha |
|
D. Information About the Patient’s Inability to Work
Briefly describe the patient’s restrictions. (SHOULD NOT DO)
Briefly describe the patient’s limitations. (CANNOT DO)
What is your prognosis for recovery?
Has patient achieved maximum medical improvement?
nYes
n No If No, please complete the following.
How soon do yo expect fundamental changes in the patient’s medical condition? |
|
||||
n |
n |
n |
n 6 months to a year |
n 1 year or more |
n Never |
|
|
|
|||
Give details concerning expected improvement or deterioration. |
|
|
|||
What is your treatment plan for the patient’s return to work or return to prior level of function?
In an
Sit |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
Stand |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
Walk |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
Are there restrictions in: |
Yes |
No |
If Yes, please fully explain below. |
Driving/Operating motorized equipment |
n |
n |
__________________________________________________________________________ |
Lifting/Carrying |
n |
n |
__________________________________________________________________________ |
Use of hands in repetitive actions |
n |
n |
__________________________________________________________________________ |
Use of feet in repetitive movements |
n |
n |
__________________________________________________________________________ |
Bending |
n |
n |
__________________________________________________________________________ |
Squatting |
n |
n |
__________________________________________________________________________ |
Crawling |
n |
n |
__________________________________________________________________________ |
Climbing |
n |
n |
__________________________________________________________________________ |
Reaching above shoulder level |
n |
n |
__________________________________________________________________________ |
Other |
n |
n |
__________________________________________________________________________ |
When do you expect the patient to return to prior level of functioning?
Would you recommend vocational rehabilitation for this patient?
nYes
nNo
E. Required Attachments and Signature
After you have fully completed this form, please attach copies of the following materials. |
|
|
|
• |
Office notes for the period of treatment received over the last two years |
• |
Hospital discharge summaries |
• |
Test results showing objective findings |
• |
Consulting physician reports |
Your Name
Specialty
Address
Degree
Telephone No. ( |
) |
Fax No. ( |
) |
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
X ____________________________________________________ |
_________________________ |
Signature of Attending Physician (no stamp) |
Date |
MUG1710A_0212 |
Page 10 of 10 |