Std 5782 Form – Fill Out and Use This PDF

The Std 5782 form is designed for employees to file a disability claim for Accident & Sickness (A&S), Short Term Disability (STD), or Salary Continuance. It requires detailed information from the employer, the employee, and the attending physician to support the claim. Completing and submitting this form promptly, as guided, can expedite the processing of your claim and help ensure that your need for financial support is met during your period of disability. For assistance with filling out the Std 5782 form, click the button below.

Get Form Now Download PDF

Std 5782 Form PDF Details

In navigating the complexities of filing a disability claim due to accident and sickness or exploring options under short-term disability and salary continuance, individuals find themselves faced with the task of completing the Std 5782 form, an essential document issued by the Metropolitan Life Insurance Company. This form serves as a comprehensive tool, guiding both the employer and the employee through the intricate process of claim submission. It is meticulously designed with sections that require detailed inputs about the employer, the employee, and even the attending physician's observations and recommendations. The form underscores the importance of providing accurate information, highlighted by a stern warning against insurance fraud which can carry severe legal implications. Furthermore, the document facilitates a smoother communication channel between all parties involved, including the insurance company, by recommending fax submission for quicker processing while also accommodating traditional mailing methods. The Std 5782 form, by bridging the gap between medical documentation and financial support, underscores a critical step in ensuring individuals receive the assistance they need during challenging times. It not only aids in expediting the claims process but also serves as a legal document that meticulously records the circumstances leading to the disability claim, including the employer’s verification, detailed medical information from healthcare providers, and explicit consent from the employee for the release of this sensitive information in line with HIPAA regulations.

Question	Answer
Form Name	Std 5782 Form
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	metlife short term disability form, metlife short term disability claim forms, metlife std claim form, metlife short term disability form pdf

Form Preview Example

DISABILITY CLAIM FOR

ACCIDENT & SICKNESS (A&S)/

SHORT TERM DISABILITY (STD)/SALARY CONTINUANCE

Instructions for completing the claim form:

1.Complete all applicable areas of the claim form. Please print clearly.

2.Please sign – a) bottom of this page and b) Fraud Statement.

3.Faxing this claim form will expedite receipt and eliminate your need to mail it.

Metropolitan Life Insurance Company

P.O. Box 14590

Lexington, KY 40512

Fax: 1-800-230-9531

New 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.

Section 1: To Be Completed by the Employer

Name of Employer

Group Report #

Sub-Code # (Sub-Division)

Sub-Point # (Branch)

Address

City

State

Zip Code

Subsidiary or Division Name

We require a street address for our records if a P.O. Box is your mailing address

Contact Person’s Name

Phone #

Contact Person’s E-mail Address

FAX #

Employee Name (First, MI, Last)

Social Security No.

Employee ID #

Date of Hire

Job Title

Job Class

 Sedentary  Light  Medium  Heavy  Very Heavy

Work Location Address

Work Phone #

Home Phone #

Supervisor Name

Supervisor’s E-Mail Address

Phone #

Is condition work related?

 Yes

 No.

If yes, provide:

W/C Carrier Name

W/C Contact Person’s Name

Phone#

Worker’s Comp Claim #

Date Last

First Date

Date Returned To Work

Eff. Date of

Basic Earnings (exclusive of overtime, bonus, etc.)

Worked

of Absence

 Actual

Coverage

 Estimated

 Hourly

 Weekly

 Bi-weekly

 Monthly  Annual

Premium contributions		 Pre-Tax
		 Pre-Tax
Employer	% Employee	%  Post-Tax

Beneﬁt Amount

Payroll Classiﬁcation  Exempt  Non-Exempt  Salaried  Hourly

Union  Non Union  Other

Employee’s Status As Of	 Active	 Vacation
First Day Absent	 LOA	 Laid Off
	 LOA	 Laid Off
	 Terminated	 Retired

Hours Worked Per Week			 Full Time	 Part Time
Scheduled Work Week  M	 Tu  W  Th  F			 Sa  Su
Is work week regular		or variable

If other than Active, please explain

If STD buy up, date enrollment card signed

LTD Coverage?

 Yes  No

Can employee’s job be modiﬁed/accommodated?

 Yes  No If yes, please describe.

Has return to work been discussed with

employee?

 Yes

 No

To the best of your knowledge, indicate if the employee has ﬁled for or is receiving income from any of the following sources:

Applied for Receiving

$ Amount

Frequency

From/To Dates

Salary Continuance/Sick Leave



Workers’ Compensation



State Disability



Other (Please identify)



Provide weekly deduction amounts, if applicable:

Pre Tax

Post Tax

$ Weekly Amount

Medical



Life



Dental



LTD



Other (Please identify)



Authorizing Signature

Date

Page 1 of 5

A&S STD 5782 (07/16) Fs

How to Edit Std 5782 Form Online for Free

When using the online PDF editor by FormsPal, you are able to fill out or modify metlife disability forms here. To have our editor on the cutting edge of practicality, we aim to put into action user-oriented features and improvements on a regular basis. We're always thankful for any feedback - play a vital role in remolding how we work with PDF documents. Starting is effortless! Everything you should do is stick to these basic steps down below:

Step 1: Click on the "Get Form" button in the top part of this webpage to get into our editor.

Step 2: The tool grants the opportunity to change PDF forms in various ways. Modify it by writing any text, correct what is already in the file, and place in a signature - all close at hand!

It is actually an easy task to complete the form using out helpful guide! This is what you should do:

1. The metlife disability forms usually requires specific details to be typed in. Make sure the subsequent blanks are complete:

metlife short term disability form writing process outlined (part 1)

2. After this section is done, it's time to add the required particulars in Premium contributions PreTax, Beneﬁt Amount, Employees Status As Of First Day, Active Vacation LOA Laid Off, If other than Active please explain, Hourly Weekly Biweekly, Payroll Classiﬁcation Exempt, Union Non Union Other Hours, If STD buy up date enrollment card, Has return to work been discussed, Applied for Receiving, FromTo Dates, Amount, Frequency, and LTD Coverage Yes No allowing you to proceed further.

Has return to work been discussed, Amount, and Frequency inside metlife short term disability form

3. This next section is focused on Section To Be Completed by, Name First MI Last, Social Security, ID Number, Date of Birth MMDDYY Gender, M F, Address City State Zip Code, Email Address, We require a street address for, Home Phone, Marital Status Married Single, Federal Tax Status Married Single, Tax Exemptions Number Date, Is your disability due to Illness, and Is this condition work related - fill in every one of these blanks.

Writing section 3 in metlife short term disability form

Always be very careful while filling in We require a street address for and Federal Tax Status Married Single, because this is the section where most users make errors.

4. Filling out Primary Diagnosis Code Diagnosis, Secondary Diagnosis Code, CPT, Procedure, Date, If pregnancy delivery date, If patient has been hospitalized, Treatment Plan Additional Testing, Medications prescribed names, Is patient able to work with job, Signature, Specialty, Tax ID, Street Address, and CityStateZip is vital in the next step - be sure to spend some time and take a close look at each and every blank area!

Secondary Diagnosis Code, Date, and Treatment Plan Additional Testing of metlife short term disability form

5. Because you near the conclusion of this file, there are just a few more requirements that have to be fulfilled. Notably, Your refusal to complete and sign, Name of Employee Please Print, Date of Birth, Claim Number, ID Number, Authorization to Disclose, For purposes of determining my, I permit any physician or other, I permit MetLife to disclose to my, and This Authorization to Disclose should be filled out.

metlife short term disability form writing process clarified (step 5)

Step 3: As soon as you've reread the information provided, simply click "Done" to conclude your form at FormsPal. Get the metlife disability forms when you register at FormsPal for a 7-day free trial. Immediately get access to the pdf file within your FormsPal account, with any edits and adjustments being conveniently kept! FormsPal guarantees your information privacy with a secure system that in no way saves or distributes any sensitive information typed in. You can relax knowing your paperwork are kept safe when you work with our tools!

Std 5782 Form – Fill Out and Use This PDF

Std 5782 Form PDF Details

Form Preview Example

How to Edit Std 5782 Form Online for Free

Std 5782 Form isn’t the one you’re looking for?

Related Documents