Liberty Mutual Long Term Disability Claim Form For Wells Fargo Employees Details

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.

QuestionAnswer
Form NameLong Term Disability Form
Form Length13 pages
Fillable?No
Fillable fields0
Avg. time to fill out3 min 15 sec
Other nameslong term disability form manulife, form long term disability, prudential long term disability application form, long term disability form on line nj

Form Preview Example

A Guide for Successfully Completing the

Group Long-Term Disability Claim Form

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 long-term disability benefits.

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: EMPLOYEES 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: EMPLOYERS 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 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: PHYSICIANS 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 SPECIC 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.

Long-Term Disability Claim Form

Mutual of Omaha Insurance Company

United of Omaha Life Insurance Company

Group Insurance Claims Management

Mutual of Omaha Plaza

 

Omaha, NE 68175-0001

 

Phone 800-877-5176

Fax 402-997-1865

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 pregnancy-related, proceed to #3 below.

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, 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?

 

 

 

 

 

 

 

 

 

 

 

 

 

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

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) 997-1865

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

___________

____________

_________________

__________________

_________________

Short-Term Disability

___________

____________

_________________

__________________

_________________

Unemployment

___________

____________

_________________

__________________

_________________

No-Fault Insurance

___________

____________

_________________

__________________

_________________

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 W-2C that is furnished to you based on recoveries received.

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) 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 ________________

 

 

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) 997-1865

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 68175-0001

or

Fax 402-997-1865

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) 997-1865

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 pre-tax dollars.

Does Employee contribute post-tax dollars toward the premium?

nYes

n No If Yes, what percent is paid by Employee? ______% Post-Tax

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) 997-1865

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 pre-disability monthly earnings?

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 (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

 

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) 997-1865

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

 

(0%-33%)

(34%-66%)

(67%-100%)

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) 997-1865

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 ICD-9 or DSM code)

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 ICD-9 or DSM)?

nYes

nNo

If this is a cardiac condition, what is the functional capacity (American Heart Association)?

n Ejection Fraction n Class 1–No Limitation n Class 2–Slight Limitation

n Class 3–Marked Limitation n Complete Limitation

 

 

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) 997-1865

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 1-2 months

n 3-4 months

n 5-6 months

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 eight-hour workday, the patient can: (Circle full hourly capacity for each activity.)

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