Long Term Disability Form – Fill Out and Use This PDF

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 long-term disability benefits with Mutual of Omaha/United of Omaha, and are agreeing to allow disclosure of personal information to the necessary parties for purposes of claim processing.

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.

C. Information For Tax Withholding

nIf this section is not completed, Mutual of Omaha will assume that premium paid by the employee is with pre-tax dollars.

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.

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.

Last Name

First Name

Middle Initial

Group Policy Number

Address

City

State/Province

ZIP

Telephone ( )

Email Address

Social Security Number

Are you currently self-employed or working for another employer? n Yes

n No If Yes, provide details.

Doctor’s Name

Doctor’s Address

Doctor’s Name

Doctor’s Address

Name of Hospital

Hospital’s Address

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

Employee’s Name

Social Security Number

Date of Birth

Employee’s Address

Employee’s Phone Number

Company’s Name

Group Policy Number

Class No. or Description

Name and Address of Medical Insurance Carrier

Is Employee covered under a Group Life policy with Mutual of Omaha? n Yes n No

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?

Do you have a pension plan? n Yes n No

If Yes, what type?

n Defined Benefit

n Defined Contribution

n401(k)

nProfit Sharing

n Other (specify)

n is salaried

n receives commissions

n receives bonuses

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?