Ufcw Trust Fund Sick Leave Form – Fill Out and Use This PDF

DRUG TRUST SICK LEAVE CLAIM FORM/DISABILITY EXTENSION APPLICATION

	CHECK ONE:	SICK LEAVE ONLY	DISABILITY EXTENSION ONLY	SICK LEAVE AND DISABILITY EXTENSION
PART 1	EMPLOYEE INFORMATION (TO BE FILLED OUT BY EMPLOYEE ONLY)

These sections must be completed by the Employee. Part 1-A and 1-B must be completed prior to the Employer completing their section.

PART 2

EMPLOYER STATEMENT (TO BE FILLED OUT BY EMPLOYER ONLY)

This section must be completed by your Employer. Your Employer may require that only certain authorized signatures be accepted. Please be sure to obtain the proper Authorized Signature. The Employer should indicate the schedule you would have worked had you not been absent due to your disability.

ADDITIONAL SECTIONS ON THE BACK OF THIS FORM

PART 3

ATTENDING PHYSICIAN'S STATEMENT (TO BE FILLED OUT BY PHYSICIAN ONLY)

In order to be paid for the first day of disability or to be paid beyond the first week of disability, this section must be completed by your doctor. You MUST be seen by your doctor within a seven-day period following commencement of the disability. Please be sure your doctor provides the date you were treated. Telephone advice does NOT satisfy this requirement. A disability day is defined as any day in which you do not work more than 50% of your scheduled shift. If you work more than 50% of your scheduled shift, this day will not be considered as a disability day and therefore will not be considered as your deductible day when not seen by a physician. In addition, to be paid for the first day you must have 180 hours in your sick leave bank on the last day of the month preceding your disability and your doctor certifies that you were unable to work because of the disability on such day of absence.

3-A

Patient Name:

Date of Birth:

Last

First

Middle Initial

MM/DD/YYYY

If

patient is still disabled, give estimated

Patient has been continuously disabled (unable to work) from:

through

date patient will be able to return to work:

MM/DD/YYYY

MM/DD/YYYY

MM/DD/YYYY

Is disability related

NO

Date(s) seen by doctor:

Diagnosis:

Diagnosis Code:

to pregnancy?

YES

; EDC

Was patient hospitalized? NO

YES

Hospital:

To:

MM/DD/YYYY

Confined From:

Name

City

State

MM/DD/YYYY

MM/DD/YYYY

3-B

Attending Physician:

Last Name:

First Name

Degree

Address:

(

)

-

Street Address

City

State

Zip Code

Phone Number

Attending Physician Signature:

X

Date Signed:

MM/DD/YYYY

IF YOUR ABSENCE LASTS LONGER THAN 7 CALENDAR DAYS, YOU MUST FILE FOR STATE DISABILITY INSURANCE (SDI)

ADDITIONAL IMPORTANT INFORMATION

(1)Disabled more than Seven Calendar Days (Three Calendar Days If Disability Caused by Work) from first day of Absence* - The Trust Fund pays in combination with State Disability Insurance (SDI) or Worker's Compensation (WC) benefits beginning your first week of disability. In order to receive your maximum benefits, you MUST file for SDI or WC and attach one of the following:

•A copy of your SDI Notice of Computation; or

•A Worker's Compensation Benefit Notice

If the Trust Fund receives this form without your SDI statement, the Trust Fund will reduce your Sick Leave benefits by the maximum State Disability benefit. You MUST submit a copy of your first SDI or WC benefit notice to the Trust Fund in order to be paid for any additional benefits that are due. Call the SDI office at (800) 480-3287 for information on SDI filing deadlines. If the amount of SDI or WC that you received was less than what the Trust Fund estimated, the Trust Fund will pay any additional benefits that are due. You will be requested to return any overpayments.

You cannot receive more than 100% of your regularly scheduled wages. SDI and WC pay first toward your regularly scheduled wages. The Trust Fund will pay the difference between your regularly scheduled wages and what SDI or WC pays, as long as you have available Sick Leave hours.

*For example: If you are first absent on a Monday due to a disability and you are still absent the following Monday (more than 7 calendar days), then SDI becomes your primary payer of lost wages. You MUST file for SDI in order to receive your entire Sick Leave Benefit amount, because your disability lasted longer than 7 calendar days.

(2)Timely Filing Limit - You will be disqualified for the Sick Leave Benefit and/or Disability Extension if you do not file your application by the following deadlines:

•Disability Extensions: 60 days from the date you receive your COBRA/ Loss of Eligibility notification for Disability Extension;

•Sick Leave: One year from the first day of your disability for Sick Leave Claims.

(3)Eligibility For Disability Extensions - Requirements include the following:

•Return this completed form to the Trust Fund office within 60 days from the date your coverage ended or you received the COBRA continuation notice. If you do not file your application within this 60-day period, you will be disqualified for a Disability Extension

•You must have been eligible for at least nine continuous months prior to the work month in which you became disabled. The Plan also required you to have sufficient qualifying hours to be eligible for benefits. The total required hours can be a combination of hours worked and hours not worked due to disability. The combination of hours worked and scheduled hours not worked must equal or exceed the minimum qualifying hours.

•If your disability lasts more than seven calendar days, you must submit proof of your disability. You can request your doctor complete Part D or you may attach the notifications you received from State Disability or Workers' Compensation for benefits paid to you for the calendar month(s) for which this extension application is made.

•If your Disability Extension Application is granted but you remain disabled when your extension expires, and you are eligible for additional extension (please confirm with Member Services if insure of your eligibility), you must file a new application within 60 days from the date the last Disability Extension expired.

•Gold and Platinum Active participants who suffer a Total and Permanent Disability (as defined by Social Security Administration or other comparable standard) will be eligible for an additional 12-month extension - if they are eligible to receive 12 Disability Extensions. To obtain this extension, you must notify the Trust Fund within 60 days of the date your total disability determination is issued.

You will receive notification from the Trust Fund Office when your application is processed. For additional information about Disability Extensions and the maximum number allowed, please refer to your Summary Plan Description.