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.

QuestionAnswer
Form NameStd 5782 Form
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesmetlife 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

 

 

 

 

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

 

 

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

*Contact MetLife at 888-444-1433 for any questions you have on completing this form.

Some services in connection with your Disability Claim may be performed by our affiliate, MetLife Global Operations Support Center Private Limited. This service arrangement in no way alters Metropolitan Life Insurance Company’s obligations to you. Services will not be performed by our affiliate if prohibited by state or local law or by mutual agreement with the Group Customer.

 

Section 2: To Be Completed by Employee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (First, MI, Last)

 

 

 

 

 

 

 

 

 

 

Social Security #

 

ID Number

 

 

 

 

Date of Birth (MM/DD/YY)

Gender

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

City

 

 

State

 

 

Zip Code

E-mail Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Phone #

Marital Status

 

 

 

 

 

Federal Tax Status

 

Tax Exemptions (Number)

Date Disability Began

 

 

 

 

 

Married Single Other

 

Married Single

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is your disability due to Illness? Injury/Accident? If due to injury/accident, provide Date

 

 

 

 

 

 

 

, Time

 

AM PM

 

Provide Details (Where and How)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is this condition work related? Yes

No

 

Automobile Related?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of physicians/providers who have treated you for this condition within the past 12 months

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Physician/Provider

 

 

 

 

 

 

 

 

Phone Number

 

 

 

Dates of Treatment

 

 

 

Physician Specialty

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From

 

 

To

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From

 

 

To

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please describe what prevents you from performing the duties of your job.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 3: To Be Completed by Attending Physician

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This report is to assist us in making a disability determination that impacts income replacement for your patient. A MetLife claim representative

 

may telephone your office if additional information is needed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Disability Began

 

 

 

 

 

 

Expected Return to Work Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Initial date of treatment for this disability

 

Most recent date of treatment

 

 

 

 

 

Is condition work-related?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary Diagnosis Code

 

 

.

 

 

 

 

 

 

 

 

Diagnosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Secondary Diagnosis Code

 

.

 

 

 

 

 

 

 

 

 

Diagnosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Objective Findings:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CPT4

 

 

 

 

Procedure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If pregnancy, delivery date

 

 

 

 

 

Expected

 

 

 

 

 

 

Actual

 

 

 

 

 

 

 

 

Type of delivery

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If patient has been hospitalized

Inpatient

Outpatient

Admitted

 

 

 

 

 

 

 

 

 

 

Discharged

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment Plan: Additional Testing

Medication Therapy

Surgery Hospitalization

 

 

Referral

 

 

 

 

 

Other (Describe)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medications prescribed (names, dosages)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is patient able to work with job modifications or restrictions? (please be specific):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

Specialty

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tax ID #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-mail Address

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone #

 

 

 

 

 

 

 

 

 

 

 

 

Fax #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 2 of 5

A&S STD 5782 (07/16) Fs

Metropolitan Life Insurance Company

P.O. Box 14590

Lexington, KY 40512

Fax: 1-800-230-9531

HIPAA: This Authorization has been carefully and specifically drafted to permit disclosure of health information consistent with the privacy rules adopted and subsequently amended by the United States Department of Health and Human Services pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

NOTE TO ALL HEALTH CARE PROVIDERS: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. ‘Genetic information’ as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

Instructions for completing the form:

1.Complete all applicable areas of the form.

2.If you are the Authorized Representative, include a copy of the legal document(s) authorizing you to act on the Employee/Claimant’s behalf.

3.Sign this form.

4.Fax or return this form as soon as possible to expedite processing of your claim – retain original for your records.

Your refusal to complete and sign this form may affect your eligibility for benefits under your employer’s disability plan.

Name of Employee (Please Print)

Date of Birth

Claim Number:

ID Number: ___________________________________

Authorization to Disclose Information About Me

For purposes of determining my eligibility for disability benefits, the administration of my employer’s disability benefit plan (which may include assisting me in returning to work, or applying for Social Security Disability Insurance benefits), and the administration of other benefit plans in which I participate that may be affected by my eligibility for disability benefits, including but not limited to any workers compensation, employee assistance or disease management program, I permit the following disclosures of information about me to be made in the format requested, including by telephone, fax or mail:

1.I permit: any physician or other medical/care provider, hospital, clinic, other medical related facility or service, pharmacy benefit administrator, insurer, employer, government agency, group policyholder, contractholder or benefit plan administrator to disclose to Metropolitan Life Insurance Company (“MetLife”), and any consumer reporting agencies, investigative agencies, attorneys, and independent claim administrators acting on MetLife’s behalf, any and all information about my health, medical care, employment, and disability claim.

2.I permit: MetLife to disclose to my employer or its agents acting in the capacity of administrator of its benefit plans or programs, including but not limited to, workers compensation, employee assistance, or disease management programs, any and all information about my health, medical care, employment, and disability claim.

This Authorization to Disclose Information About Me specifically includes my permission to disclose my entire medical record, including medical information, records, test results, and data on: medical care or surgery; psychiatric or psychological medical records, but not psychotherapy notes; and alcohol or drug abuse including any data protected by Federal Regulations 42 CFR Part 2 or other applicable laws. Information concerning mental illness, HIV, AIDS, HIV related illnesses and sexually transmitted diseases or other serious communicable illnesses may be controlled by various laws and regulations. I consent to disclosure of such information, but only in accordance with laws and regulations as they apply to me. Information that may have been subject to privacy rules of the U.S. Department of Health and Human Services, once disclosed, may be subject to redisclosure by the recipient as permitted or required by law and may no longer be covered by those rules. Your health care provider may not condition your treatment on whether you sign this authorization.

I understand that I may revoke this authorization at anytime by writing to MetLife Disability at P.O. Box 14590, Lexington, KY 40512-4590, except to the extent that action has been taken in reliance on it. If I do not, it will be valid for 24 months from the date I sign this form or the duration of my claim for benefits, whichever period is shorter. A photocopy of this authorization is as valid as the original form and I have a right to receive a copy upon request.

Signature of Employee

Date

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A&S STD 5782 (07/16) Fs

Disability Claim Statement (Continued)

Fraud Warning:

Before signing this claim form, please read the warning for the state where you reside and for the state where the insurance policy under which you are claiming a benefit was issued.

Alabama, Arkansas, District of Columbia, Louisiana, Massachusetts, Minnesota, New Mexico, Ohio, Rhode Island and West Virginia – Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Alaska – A person who knowingly and with intent to injure, defraud or deceive an insurance company files a claim containing false, incomplete or misleading information may be prosecuted under state law.

Arizona – For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of loss is subject to criminal and civil penalties.

California – 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.

Colorado – 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 from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Delaware, Idaho, Indiana and Oklahoma – WARNING: Any person who knowingly and with the intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Florida – Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Kentucky – Any person who knowingly and with the intent to defraud any insurance company or other person files a 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.

Maine, Tennessee, Virginia and Washington – It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

Maryland – 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.

New Hampshire – A person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

New Jersey – Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

Oregon and Vermont – Any person who knowingly presents a false statement of claim for insurance may be guilty of a criminal offense and subject to penalties under state law.

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A&S STD 5782 (07/16) Fs

Disability Claim Statement (Continued)

Fraud Warning (continued):

Puerto Rico – Any person who knowingly and with the intention to defraud includes false information in an application for insurance or files, assists or abets in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years.

Texas – 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.

Pennsylvania and all other states – Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning a fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Name of Employee (Please Print):

 

Social Security Number:

Signature of Employee

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

Signature of Employer’s Representative

 

Date:

 

 

 

 

 

Signature of Physician

 

Date:

 

 

 

 

 

Page 5 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:

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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)

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