MEMBERS BENEFIT FUND Hourly Construction Division. APPLICATION for SHORT TERM DISABILITY BENEFITS

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1 MEMBERS BENEFIT FUND Hourly Construction Division APPLICATION for SHORT TERM DISABILITY BENEFITS

2 L. I. U. N. A. L o c a l IMPORTANT INFORMATION If you become disabled, while covered, because of either a non-occupational illness or a non-occupational accidental injury and you cannot perform your job duties, you may be entitled to Short Term Disability Benefits. In order to be eligible for Short Term Disability Benefits: Employer contributions must have provided your coverage on the date your disability commences. You are not eligible for disability benefits if your benefits coverage has been terminated or if your benefits coverage is being maintained through self-payment. You must also be actively at work immediately prior to your disability. If you have been laid off, terminated, or not working for any other reason, Short Term Disability benefits may be denied. The provisions of your Short Term Disability Benefits policy are as follows: Disability must be as a result of a non-occupational illness or a non-occupational accidental injury that prevents you from performing the essential duties of your job; You must be diagnosed with a bona fide medically-supported illness or injury which prevents you from performing the essential duties of your job; You must see a licensed physician within 48 hours of your disability. If this was not done you may be required to provide an explanation as to why you were unable to see a physician in a timely fashion; Your disability period will not be considered to start until a licensed physician has seen you and treated you for this condition or injury; Benefits commence on the 1st day of disability if resulting from a non-occupational accident, if you have been hospitalized for over 18 hours, or if you had a surgical procedure under general anesthetic. Benefits commence on the 8th day of disability if resulting from a non-occupational illness/condition; Short Term Disability Benefits are integrated with Employment Insurance (EI) Sickness Benefits. If you are eligible for EI, you will receive Short Term Disability Benefits during the EI Waiting Period, but your benefits will be suspended when EI benefits are payable. Short Term Disability Benefits are reinstated should EI Sickness Benefits expire and you continue to meet the eligibility requirements; 1263 Wilson Avenue, Suite 209, Toronto, ON M3M 3G2. Tel.: (416) Fax: (416) Toll Free:

3 L. I. U. N. A. L o c a l The maximum Short Term Disability Benefits period, inclusive of the 15 weeks of Sickness Employment Insurance Benefits, waiting period, or any period of non-compliance, is 104 weeks from the date of disability; A maximum benefit of up to $100 for the completion of the initial Disability Application Physician Statement is payable should the claim be approved. The eligibility conditions to remain eligible for Short Term Disability Benefits are as follows: You must participate in a diagnostically-based treatment program focused on recovery; You must be compliant with the treatment plan set forth by your medical practitioners which includes: Attending required appointments with your physicians, specialists, and treatment providers; Attending all recommended tests, investigations, and diagnostics; Participating in temporary modified work plans when accommodations are identified; Communicating regularly with the case worker. OTHER GENERAL INFORMATION Should your benefit coverage terminate due to insufficient credits, you may exercise the option to continue your benefit coverage by making Self-payments to the Members Benefits Plan. If there are any questions, contact the Members Benefits Plan Administrators at or at Please contact the Members Benefits Plan Administrators about possible entitlement to other benefits and/or services offered under the Members Benefit Plan. They can be reached at or at Payment of monthly Union Dues is your responsibility and you must pay ongoing dues to remain in good standing. If there are any questions, please contact LIUNA Local 183 at or at If you will be off work for a prolonged period of time, speak to the Labourer s Pension Fund for guidance on pension matters at If you or your eligible dependents need assistance during times of stress, the Member & Family Assistance Program (MFAP) provides eligible members and their eligible dependents access to professional counseling services without service fee. The Member & Family Assistance Program is a confidential service. They can be reached at Wilson Avenue, Suite 209, Toronto, ON M3M 3G2. Tel.: (416) Fax: (416) Toll Free:

4 L. I. U. N. A. L o c a l APPLICATION PROCESS 1. Complete all sections of the Member Statement and sign the Authorization to Release Medical Information; 2. Ensure the Employer Section is completed by your last employer. 3. Please attach a copy of your Record of Employment (ROE) issued by your employer, if available. 4. Apply for Employment Insurance (EI) Sickness Benefits immediately. 5. Have your treating physician complete the Attending Physician Statement. Attach any additional relevant medical information. 6. Return the completed application to in a timely manner: Fax: or Drop-off: Mail: Wilson Avenue, West Wing, Suite 302, Toronto, ON. M3M 2G Wilson Avenue, Suite 209, Toronto, ON. M3M 2G2 Please refer to the Members Benefit Fun Benefits Booklet for additional information regarding the provisions of the plan. Please contact us at if you have any other questions regarding Short Term Disability Benefits or the application process Wilson Avenue, Suite 209, Toronto, ON M3M 3G2. Tel.: (416) Fax: (416) Toll Free:

5 SHORT TERM DISABILITY BENEFITS APPLICATION NOTE TO LIUNA LOCAL 183 MEMBER As for any insurance plan, you must apply and qualify to receive Short Term Disability Benefits. Please follow these instructions: Ensure you are eligible for benefits offered by the LIUNA Local 183 Members Benefit Plan at the time of your disability; Complete the Member Statement and Authorization to Release Medical Information; Ensure your Employer Statement is completed by your last employer and attach a copy of Record of Employment (ROE); Ensure your treating physician completes and returns the Physician Statement; Urgently fax completed forms to / or Mail to Wilson, Suite 209. Toronto, ON. M3M 2G2 or drop off at - Local 183 Union Hall, Suite 302. Apply for Employment Insurance (EI) Sickness and Illness Benefits; Comply with the treatment plan recommended by your physician and treatment providers. 1. MEMBER STATEMENT Last Name: Given Name(s): Address: City, Province: Postal Code: Social Insurance #: Tel # / Cell #: Date of Birth (Month/ Day / Year): Last Day Worked (Month / Day / Year): 1 st Day Missed (Month / Day / Year): Accident / Illness date (Month / Day / Year): Is this Injury / Illness Work-Related? [ ] Yes [ ] No Is this Injury due to a Motor Vehicle Accident? [ ] Yes [ ] No Please describe how the accident occurred and/or the nature of your condition: AUTHORIZATION I hereby authorize each and every physician, health care professional, hospital, health care institution, or provider to provide Organizational Health Ontario Inc. (OHI) & Benefit Plan Administrator Ltd (BPA), third party providers, all information and documents requested concerning my medical and/or behavioral health condition relative to this claim for the purpose of facilitating the delivery of best practice medical care and the assessment of my ability to work. This authorizes OHI & BPA to provide all related medical information and documents to the long-term disability insurer should I need to apply for Long-Term Disability benefits. This authorization is valid from the date hereof through the date of return to work to full duty. Only the information relating to my ability to work will be shared with my employer. All information will be treated in a highly confidential manner. Member Signature: (Required) Date: Member s Name: 2. EMPLOYER STATEMENT Job Title: Date of Hire: Weekly Wages: Reason for Work Absence: Last Day Worked (Month / Day / Year): Are Modified Duties / Hour Available: [ ] Yes [ ] No Explain Return to Work Date (Month / Day / Year):, if applicable Company Name: Tel #: Employer Contact Name: Title: DECLARATION I hereby declare that the answers to the above questions are accurate and complete. Employer Signature: (Required) Page 1 of 2 Date:

6 SHORT TERM DISABILITY BENEFITS APPLICATION 3. PHYSICIAN STATEMENT LIUNA Local 183 is interested in supporting ill and injured members in their recovery and safe, timely return to work. Organizational Health Ontario Inc. (OHI) has been requested to review medical absences to determine eligibility to benefits, ability to return to work and co-ordinate the member s recovery and return to work. Please complete the questions below. Any fees required for the completion of this form are the responsibility of the member. Please provide a receipt to your patient so that they present this for reimbursement. Please feel free to attach any additional documentation to help us understand the nature and extent of your patient s disability. Fax completed and signed forms to (416) or Patient s Name: Date of Birth (MM / DD / YYYY): Your Patient Since (MM / DD / YYYY): Date of Onset (MM / DD / YYYY): Date First Seen for This Condition: Date First Seen after Work Absence: Diagnosis (if mental health, please provide DSMIV diagnosis): Secondary Diagnoses / Signs & Symptoms: Restrictions and Limitations: Is this a result of an Accident: [ ] No [ ] Yes, describe accident / mechanism of injury: Is this Injury/Illness Work-Related: [ ] Yes [ ] No Is this Injury/Illness due to an MVA: [ ] Yes [ ] No Can Patient Perform Modified Duties: [ ] Yes [ ] No List Work Restrictions and/or Graduated Return to Work Plan: Can Patient Perform Modified Hours: [ ] Yes [ ] No Treatment Plan: Medications: Rehabilitation: [ ] Yes [ ] No Type / Location: Hospitalization: [ ] Yes [ ] No From / To: Surgery: [ ] Yes [ ] No Date and Type: Specialists Involved in Care: [ ] Yes [ ] No Name / Specialty: Compliant with Care: [ ] Yes [ ] No, if no please explain: Diagnostic Testing Performed: [ ] Yes [ ] No Date and Type: Surgery Under General Anesthesia: [ ] Yes [ ] No Next Appointment with you: Frequency of Visits: [ ] Weekly [ ] Bi-Weekly [ ] Monthly [ ] As Needed Estimated Return to Work date: Is there any other information you wish to add to give us a better understanding the nature of your patient s condition or treatment needs? Physician s Name: Physician s Address: Physician s Signature: Page 2 of 2 Phone: Fax: Date:

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