Short Term Disability Claim Form

A Guide for Successfully Completing the
Group Short-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 short-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
Prior to submission, make sure you have provided
all required information and answered all questions
completely and accurately. If information is missing or
cannot be read, the processing of your form will be delayed.
n The following guidelines provide valuable information to
help you successfully complete the form.
n Please make a copy of the completed form for your records
before submitting it to Mutual of Omaha/United of Omaha.
n
Section 1: Employee Statement
This section is to be completed by the Employee. Dates
should include the month, date and year. In order to be
considered complete, the form must be signed by you.
Group ID Number for your Employer will consist of eight
characters, beginning with “G000” and followed by four
additional letters or numbers specific to your Employer.
n Job Title is the title of your position held with the Employer.
n The Hours Worked per Week is the number of hours you
worked per week for the Employer.
n Height should be provided in feet and inches.
n Weight should be provided in pounds.
n Dominant Hand indicates whether you are primarily rightor left-handed.
n Date of Disability is the first day you were absent from work
because of the disabling condition.
n Date First Treated is the date you first sought medical care
because of the disabling condition.
n Other 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.
n
Authorization to Disclose Personal Information &
Authorization to Disclose Health Information
to my Employer
Both authorizations are to be completed by the Employee.
Dates should include the month, date and year. In order to be
considered complete, the form must be signed by you or your
legal representative.
By signing the authorization, you are applying for shortterm disability benefits with Mutual of Omaha/United of
Omaha and are agreeing to allow disclosure of personal
information to the necessary parties for the purpose of
claim processing.
n If 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.
n
Guidelines for Section 2: Employer’s Statement
This section is to be completed by the Employer. Dates should
include the month, date and year. In order to be considered
complete, the form must be signed by the Employer.
Group ID Number consists of eight characters, beginning
with “G000” and followed by four additional letters or
numbers.
n Date Covered Under This Plan indicates the date in which
the Employee’s coverage became effective.
n If the Employee is eligible for salary continuation/sick
leave, this does not include Mutual of Omaha/United of
Omaha short-term disability benefits, paid time off or
vacation compensation.
n
Guidelines for Section 3: Attending Physician’s
Statement
This section is to be completed by the Attending Physician.
Dates should include the month, date and year. In order to
be considered complete, the form must be signed by the
Attending Physician.
Required Fraud Warnings
Before completing the claim form, please read the Required
Fraud Warnings listed on the following page.
MUG6110A_0114
STD Claim Form Guide_1009
Please read – State specific warnings apply to the resident of such state
Fraud 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.
n
Alabama: 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.
n
Arkansas/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.
n
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.
n
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 payable from insurance
proceeds shall be reported to the Colorado division of
insurance within the department of regulatory agencies.
n
District of Columbia: WARNING: 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.
n
Kansas: 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.
n
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.
n
MUG6110A_0114
New Jersey: Any person who knowingly files a statement
of claim containing any false or misleading information is
subject to criminal and civil penalties.
n
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.
n
Oregon: 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.
n
Puerto 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.
n
Rhode 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.
n
Vermont: 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.
n
Virgin Islands: 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 penalties.
n
Virginia: 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.
n
STD Claim Form Guide_1009
Short-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
Email [email protected]
Section 1 – Employee Statement (Answer all questions to avoid delay)
Current Employer’s Name
Group ID Number
Job Title
Name
Address
City
(Area Code) Home Telephone Number
(Area Code) Cellular Telephone Number
Hours Worked
per Week
StateZIP
Social Security Number
Email Address
Date of Birth
Height
Weight Dominant Hand: ■ Right
■ Left
Date of Disability (1st Day Absent)
■ Male
■ Female Date First Treated
■ Single
■ Married
■ Widowed
■ Divorced
Estimated Return to Work Date
Nature of illness and when symptoms first appeared, or describe how and where accident occurred.
Was the disability work related? ■ Yes
■ No
Have you filed a Workers’ Compensation claim? ■ Yes
Was disability related to a motor vehicle accident or is another third party liable? ■ Yes
■ No
■ No
Physician’s Name
Other income you have filed for, are receiving, or are eligible for:
Amount
Date Claim Filed
Date Benefits Began
Workers’ Compensation
$_________________
___________________________
___________________________
State Disability
$_________________
___________________________
___________________________
$_________________
___________________________
___________________________
Other
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.
Important Notice: If you have group life insurance through your employer, please contact your benefits administrator as soon
as possible to determine what options are available to you to continue your life insurance. Some options require action within
31 days of the date you stop working/insurance ends for life insurance to continue.
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.
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.
Employee’s Signature:_____________________________________________________ Date:______________________________
MUG6110A_0114
Page 1 of 6
Form continued on Page 2
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
Or
Email [email protected]
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 contiguous 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 disclosure 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
MUG6110A_0114
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Form continued on Page 3
Authorization to Disclose Health Information to My Employer
I authorize Mutual of Omaha Insurance Company and United of Omaha Life Insurance Company to disclose health information
about me to my employer, and to my employer’s broker. I understand that this information will be used by my employer, and
its broker, to monitor and manage the disability benefits program provided under my Group disability policy. I also understand
that my employer and its broker will use the information solely for the purposes of auditing disability benefits paid, providing
claims assistance, determining waiver or discontinuance of premium deductions, and coordinating with other subsidized salary
continuance plans my employer may offer.
The health information which may be disclosed pursuant to this authorization includes such items as medical history, mental
and physical condition, prescription drug records and alcohol or drug use.
I understand that I may refuse to sign this authorization. I realize that if I refuse to sign, my claim for benefits may not be paid.
This authorization will remain in effect for 24 contiguous months from the date I sign it. I understand that I may revoke this
authorization at any time. If I would like to revoke this authorization, I should send my revocation request to:
ATTN: 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
Or
Email [email protected]
I also understand that any revocation of this authorization will not affect any use or disclosure of health information that
occurred prior to receipt of my revocation.
I understand that I am entitled to receive a copy of this authorization. A copy of this authorization is as effective as
the original.
___________________________________________________________________________________________________________
(Printed Name and Address)
________________________________________________________________________
Signature ________________________________
Date
or
If Applicable: I am the legal representative of the person whose financial and health information is to be disclosed, but I am
authorized to grant permission on behalf of that person.
Printed Name of Legal Representative:___________________________________________________________________________
Signature of Legal Representative:_______________________________________________________________________________
Type of Legal Representative:___________________________________________________________________________________
Date: ___________________________
RETAIN A SIGNED COPY FOR YOUR RECORDS
MUG6893_0212
MUG6110A_0114
Page 3 of 6
Form continued on Page 4
FAX (402) 997-1865
Page 4 of 6
Form must be completed in full at no expense to Mutual of Omaha
Email [email protected]
Section 2 – Employer’s Statement (Answer all questions to avoid delay)
Company Name
Group ID Number
Class No. or Description
Division/Location No. or Description
Address
City
Master Policy Number
StateZIP
Email Address
Employee’s Name
Employee’s Phone Number
Employee Address
Employee City
Weekly earnings as defined by the Plan: ________________
(Please note: Benefits will be calculated based on premium received.)
Salary Effective Date: _____________________________________________
Was disability caused by employment? ■ Yes
■ No
Employee State
Number of weekly hours worked: _________
Has workers’ compensation claim been filed? ■ Yes
Does the Employee contribute toward the premium? ■ Yes
Employee ZIP
■ No
■ No
If yes, what percent is paid by the Employee? ______% Is it Pre-tax or Post-tax? _________________
Employee’s payroll classification ■ Exempt
■ Non-Exempt
■ Salaried
■ Hourly
■ Union
■ Non-Union
■ Other
How was the Employee paid?
Is this Employee eligible for salary continuation/sick leave? ■ Yes ■ No
If yes, what is the weekly amount? $____________
When do benefits begin? __________________ End? __________________
Date of Hire: Date Covered Under This Plan:
Does Mutual of Omaha cover the Employee for group long-term disability? ■ Yes
■ No
Does United of Omaha Life Insurance Company cover the Employee for group life? ■ Yes
■ No
If so, please complete the following.
Name of Employee’s beneficiary according to your records:______________________________________ Relationship to Employee:_______________________
Important Notice: For Employees age 60 or over, refer to the policy provisions regarding group life continuation and conversion rights.
Does Mutual of Omaha cover the employee under an additional short-term disability policy? ■ Yes ___________________ (policy number)
■ No
Please contact Employee’s direct supervisor and then circle the strength demand below which best describes the Employee’s job:
{
S – Sedentary
L – Light
Circle
One
M– Medium
H – Heavy
V – Very Heavy
10 lbs. Maximum lifting, occasional lift/carry of small articles. Some occasional walking or standing may be required.
20 lbs. Maximum lifting with frequent lift/carry up to 10 lbs. A job is light if less lifting is involved but
significant walking/standing is done or if done mostly sitting but requires push/pull on arm or leg controls.
50 lbs. Maximum lifting with frequent lift/carry up to 25 lbs.
100 lbs. Maximum lifting with frequent lift/carry up to 50 lbs.
Over 100 lbs. Lifting with frequent lift/carry over 50 lbs.
Employee’s Job Title Last Day at Work
What was the Employee’s employment status on the first day absent?
Description of major job duties – Please attach job description
Can the Employee’s job be modified? ■ Yes
Has the Employee returned to work? ■ Yes ■ No
a) If yes, when?
b) If not, what is the estimated return to work date?
■ No
Signature of Person Completing Claim Form
Date Signed
(Area Code) Phone Number
Title of Person Completing Claim Form
(Area Code) Fax Number
Email Address
Please notify us if the Employee returns to work after the submission of this form.
MUG6110A_0114
Page 4 of 6
Form continued on Page 5
FAX (402) 997-1865
Page 5 of 6
Form must be completed in full at no expense to Mutual of Omaha
Email [email protected]
Section 3 – Attending Physician’s Statement (Answer all questions to avoid delay)
Employer Name
Group ID Number
Name of Patient (Last, First, MI) – Please Print
Date of Birth
Employee Address
Employee’s Phone Number
Employee City
Employee State
Diagnoses
ICD-9 Code(s)
Symptoms
Date symptom first appeared
Initial date of treatment:
Is disability due to: ■ Accident/Injury
Last date of treatment:
■ Sickness
Employee ZIP
Next date of treatment/office visit:
Is the disability work related? ■ Yes
■ No
If applicable, list the surgical procedure(s) – Describe fully and provide dates if any.
If disability is due to Pregnancy, please provide the information below:
Date of Last Monthly Period
Expected Date of Delivery
Expected Type of Delivery
Actual Date of Delivery
Actual Type of Delivery
■ Vaginal
■ Vaginal
■ Cesarean Section
■ Cesarean Section
If any of the following questions are answered “Yes,” then please provide the information to the right of that question.
Was the patient treated in an
Emergency Room?
■ Yes
■ No
Date treated
Name of Hospital
Did another physician treat or will be
treating the patient?
■ Yes
■ No
Date treated Physician’s Name and Address
Was the patient hospital confined?
■ Yes
■ No
Date Confined In Hospital:
From______________ To________________
Did patient have outpatient surgery in a hospital
or ambulatory surgical center? ■ Yes
■ No
Date of Surgery
Name of Physician
Name of Hospital
Name of Facility
Functional Limitations – Abilities
Indicate frequency per day the listed activity can be performed.
Indicate longest single time duration each activity can be performed.
(n = never, o = occasional, f = frequent, c = constant)
Lifting
Carrying
_____ Sitting
__________1-5 lbs.
__________1-5 lbs.
_____ Total time on feet
_____ L: Finger Dexterity
__________6-10 lbs.
__________6-10 lbs.
_____ Standing
_____ R: Below Shoulder
__________11-25 lbs.
__________11-25 lbs.
_____ Walking
_____ L: Below Shoulder
__________26-50 lbs.
__________26-50 lbs.
_____ Bending
_____ Outside
_____ R: Above Shoulders
__________51-100 lbs.
__________51-100 lbs.
__________Over 100 lbs.
__________Over 100 lbs.
_____ Squatting
_____ Stooping
_____ Working with _____ L: Above Shoulders
Others
_____ Other (explain)__________________________________
_____ Kneeling
_____ Inside
_____ R: Finger Dexterity
}
Reaching
Please notify us if the Employee returns to work after the submission of this form.
MUG6110A_0114
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Form continued on Page 6
FAX (402) 997-1865
Page 6 of 6
Form must be completed in full at no expense to Mutual of Omaha
Email [email protected]
Mental Limitations – Abilities
Please check off the appropriate response of the person’s ability to adapt to these specific job situations at this time.
Somewhat
Markedly
Unable to
UnlimitedLimited Limited Perform
Follow work rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Perform repetitive, or short cycle work . . . . . . . . . . . . . . . . . . . . . . . Perform at a constant pace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Maintain attention and concentration . . . . . . . . . . . . . . . . . . . . . . . Perform a variety of duties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Understand, remember and carry out complex job instructions . . Attain set limits and standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Relate to co-workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interact with supervisors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interact with the public/customers . . . . . . . . . . . . . . . . . . . . . . . . . . Use judgment and make decisions . . . . . . . . . . . . . . . . . . . . . . . . . . Direct, control or plan activities of others . . . . . . . . . . . . . . . . . . . . Influence people in their opinions, attitudes and judgments . . . . Expressing personal feelings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Work alone or apart in physical isolation from others . . . . . . . . . . . What functions of the person’s own/usual occupation is the person unable to perform? (Please provide rationale here, if not already provided.)
What functional restrictions have been placed on this person?
The patient has been continuously disabled (unable to work) from ____________________________ to ____________________________
Is the patient able to work with job modifications? ■ Yes
The patient should be able to work ■ Full-time
■ 1 month
■ 1-3 months
■ 3-6 months
■ No
■ Part-time on ______________________ or a specific date is unavailable, in
■ Other (please specify)
Remarks and/or treatment plan
Name of the Attending Physician – Please Print
Specialty/Degree(s)
Tax Identification Number
Address (No., Street, City, State, ZIP)
(Area Code) Telephone Number
(Area Code) Fax Number
If necessary, whom can we contact at the attending physician’s office for additional information?
Name:
(Area Code) Telephone Number:
Signature of Attending Physician
Date
Please notify us if the Employee returns to work after the submission of this form.
MUG6110A_0114
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