Group Life and/or Accident Coverage Disability Claim Form for Employee or Dependent

Transcription

1 Administered by: Group Life and/or Accident Coverage Disability Claim Form for Employee or Dependent IMPORTANT INSTRUCTIONS FOR COMPLETING CLAIM FORM(s) To the Employer/Employee, as applicable: We know this is a difficult time and we want to assist you in filing your claim as quickly as possible. This claim form should be used for Group Life and/or Accident Coverage, specifically for benefits pertaining to Disability, Waiver of Premium, Continuation of Insurance, Paralysis, Brain Injury claims. Part I Employer Statement, Employee Statement and Important Notice The upper portion of page 2 of the claim form is to be completed and signed by the Official Representative of the Employer of the covered employee. Submission of the claim for any voluntary or contributory (coverage where the employee pays a portion of or all of the premium) should include a copy of the enrollment form and proof of premium deductions at the time of loss. The lower portion of page 2 and upper portion of page 3 should be completed and signed by the Covered Employee. Please furnish any newspaper accounts, police or motor vehicle reports, and/or other pertinent information regarding the injury, if available and applicable. If the claim form is being completed by a Power of Attorney, a certificate of such person s legal appointment and qualification must be attached to this form. If the claim is for a college age dependent child enrolled in an accredited school of higher learning, submitted documents should include a student enrollment verification form executed by the school. Part II Attending Physician s Statement Page 4 and 5 are to be completed by the Attending Physician. Release of claim forms is not an admission of coverage under a policy or for an employer, group or association. L B REV 3/2004 1

2 Administered by: Underwriting Company (Herein called the Company ): * CNA Group Life Assurance Company Continental Assurance Company Continental Casualty Company The Hartford Group Operations PO Box Maitland, FL GROUP LIFE/ACCIDENT COVERAGE - DISABILITY CLAIM FORM THIS STATEMENT IS TO BE COMPLETED PROMPTLY TO AVOID CLAIM DELAY. PLEASE ANSWER ALL QUESTIONS COMPLETELY. FOR CLAIMS ASSISTANCE, CALL PART I STATEMENT OF EMPLOYER OR TRUSTEE Employee Name Insured Person (If other than Employer) Select Type of Claim Disability Waiver of Premium/COI Paralysis Brain Injury Name Of Group/Employer Policy Or Account Number Type Of Policy Life Accident Group Travel Effective Date Of Insurance Cancellation Date (If applicable) Certificate Number (If applicable) Date of Hire Termination Date (if applicable) Date Last Worked Date Eligible For Benefits Amount Of Insurance Monthly Salary Attach W2 If Applicable Primary Beneficiary Designations (please attach designation form) Is Insured Receiving Any Other Weekly Or Monthly Disability Benefits? No If "", Give Details: Source Of Benefits Amount - Date Benefits Began Or Will Begin. Has This Employee Requested Conversion Privilege In Order To Obtain An Individual Policy? No Are There Any Reasons For You To Question The Validity Of The Claim? If So, Give Particulars ( ) Signature Of Trustee Or Employer Representative Date Telephone Number STATEMENT OF COVERED EMPLOYEE OR MEMBER Claimant s Last Name First Middle Date Of Birth Social Security No. Present Address - No. & Street City State Zip Code Telephone Number Describe Fully The Daily Duties Of Your Job Describe Medical Condition Was An Accident Involved? No If, were You At Work When It Happened? No Date When You Last Reported For Work Date When You Expect To Return Date Of First Medical Treatment For This Condition Full Time Part Time Are You Now Engaged In The Duties Of Any Occupation Or Endeavor For Wages, Profit Or Compensation? No If, Please Explain: What Physicians Have Treated Or Prescribed For You For This Sickness Or Injury? (Names) (Addresses) (Names And Addresses Of Hospitals Confined To During This Disability) L B REV 3/2004 2

3 Are You Receiving Any Benefits As A Result Of Your Disability? No If "", Check Applicable Boxes & Complete Requested Information: (Amount) (Date Benefit Began, Or Will Begin) No Social Security Disability No Worker's Compensation No Pension Plan No Federal State, Municipal Or Other Government Agencies If You Are Not Receiving Benefits From Any Of The Above Mentioned Sources, Have You Filed Or Do You Intend To File For Such Benefits? Give Complete Details Below. Additional Comments: * The Hartford is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life and Accident Insurance Company, Hartford Life Insurance Company and CNA Group Life Assurance Company (pending state approval of name change to Hartford Life Group Insurance Company ). I AUTHORIZE The Hartford to release all of its collected health and financial information concerning me, including medical record information, for the purpose of evaluating my claim(s) for Life, Accident, or Disability Income benefits administered or insured by the The Hartford. I AUTHORIZE The Hartford to provide a complete copy of my claim file and/or information concerning my health and finances, claim status, or summaries thereof, to my employer through the appropriate employee benefit/human resources coordinators for the purpose of processing my claim(s) or for the proper administration of the employer s group benefit plan, including any disclosures which may be needed in order to facilitate my return to work with my employer. I further Authorize The Hartford to disclose any collected health or financial information, including medical record information, to my employer s Workers Compensation carrier, in the event I file a Workers Compensation claim and such information is requested of The Hartford. I UNDERSTAND that I may receive a copy of this authorization and that this authorization is valid for the entire duration of my claim. I UNDERSTAND that I may revoke this Authorization at any time by providing written notice to The Hartford, except to the extent that an individual has taken action in reliance upon such authorization prior to notice of the revocation. I AGREE that a photographic copy of this authorization shall be as valid as the original. DATED 20 SIGNED **IMPORTANT NOTICE** RESIDENTS OF ALL STATES EXCEPT AZ, CA, FL, NH & NJ: Any person who knowingly and with the intent to defraud any insurance company or other person files an application for insurance or settlement 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. AZ Residents: 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 a loss is subject to criminal and civil penalties. CA Residents: For your protection California law requires the following statement to appear on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. FL Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. NH Residents: Any 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. NJ Residents: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. L B REV 3/2004 3

4 Administered by: Underwriting Company (Herein called the Company ): * CNA Group Life Assurance Company Continental Assurance Company Continental Casualty Company GROUP LIFE/ACCIDENT COVERAGE DISABILITY CLAIM FORM Part II ATTENDING PHYSICIAN S STATEMENT THE PATIENT IS REPSONSIBLE FOR THE COMPLETION OF THIS FORM WITHOUT EXPENSE TO THE COMPANY Name of patient Date of birth / / Mo. Day Yr. Employer Name Group/Policy No. 1. HISTORY (a) When did symptoms first appear or accident happen?...mo. Day 20 (b) Date patient ceased work because of disability...mo. Day 20 (c) Has patient ever had same or similar condition?... No If "" state when and describe... (d) Is condition due to injury or sickness arising out of patient's employment? No Unknown (e) Names and addresses of other referring or treating physicians: 2. DIAGNOSIS (including any complications) (a) Date of last examination?...mo. Day 20 (b) Diagnosis (including any complications) (c) Subjective symptoms: (d) Objective findings (Including current X-rays, EKG's, Laboratory Data and any clinical findings) 3. DATES OF TREATMENT (a) Date of first visit?...mo. Day 20 (b) Date of last visit?...mo. Day 20 (c) Frequency : Weekly Monthly Other (Specify) 4. NATURE OF TREATMENT (Including Surgery and Medications Prescribed, if any) 5. PROGRESS (a) Has patient... Recovered? Improved? Unchanged? Retrogressed? (b) Is Patient... Ambulatory? House confined?... Bed confined? Hospital confined? (c) Has patient been hospital confined? No If yes, give Name and Address of Hospital Confined from through 6. CARDIAC (If Applicable) (a) Functional capacity... Class 1 (No limitation) Class 2 (Slight limitation) Class 3 (Marked limitation) Class 4 (Complete limitation) (b) Blood Pressure (last visit)... SYSTOLIC / DIASTOLIC L B REV 3/2004 4

5 7. PHYSICAL IMPAIRMENT (*as defined in Federal Dictionary of Occupational Titles) Class 1- No limitation of functional capacity; capable of heavy work* No restrictions.(0-10%) Class 2- Medium manual activity* (15-30% ) Class 3- Slight limitation of functional capacity; capable of light work* (35-55%) Class 4- Moderate limitation of functional capacity; capable of clerical/administrative (sedentary) activity* (60-70%) Class 5- Severe limitation of functional capacity; incapable of minimal (sedentary) activity* ( %) Current limitations/restrictions: 8. MENTAL/NERVOUS IMPAIRMENT (If Applicable) (a) Please define "stress" as it applies to this claimant. (b) What stress and problems in interpersonal relations has claimant had on job? Class 1- Patient is able to function under stress and engage in interpersonal relations (no limitations) Class 2- Patient is able to function in most stress situations and engage in most interpersonal relations (slight limitations) Class 3- Patient is able to engage in only limited stress situations and engage in only limited interpersonal relations (moderate limitations) Class 4- Patient is unable to engage in stress situations or engage in interpersonal relations (marked limitations) Class 5- Patient has significant loss of psychological, physiological, personal and social adjustment (severe limitations) Remarks: Do you believe the patient is competent to endorse checks and direct the use of the proceeds thereof? No 9. PROGNOSIS PATIENT'S JOB ANY OTHER WORK (a) Is patient now totally disabled?. No No (b) What duties of patient's job is he/she incapable of performing? Do you expect a fundamental or marked change in the future?... No No If yes, when will patient recover sufficiently to perform duties / / 1 Mo. 3-6 Mos. / / 1 Mo. 3-6 Mos. Mo. Day Yr. 1-3 Mos. Never Mo. Day Yr. 1-3 Mos. Never (c) Is patient capable of working full-time at a seated level type of work activity, with the availability of standing or stretching as needed? No 10. REHABILITATION (a) Is patient a suitable candidate for further rehabilitation services? (i.e., cardiopulmonary program, speech therapy, etc.)... No (b) Could patient return to work if accommodations are made to meet restriction/limitations noted in question 7 above?... No PATIENT'S JOB ANY OTHER WORK (c) When could trial employment commence? / / Full-Time / / Full-Time Mo. Day Yr. Part-Time Mo. Day Yr. Part-Time (d) Would vocational counseling and/or retraining be recommended?... No PLEASE ATTACH RECENT OFFICE NOTES, CONSULTATION REPORTS, OR ANY DIAGNOSTIC TESTS THAT ILLUSTRATE CURRENT LIMITATIONS AND RESTRICTIONS Name (Attending Physician) Print Degree Telephone/Fax Street Address City or Town State or Province Zip Code Signature * The Hartford is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life and Accident Insurance Company, Hartford Life Insurance Company and CNA Group Life Assurance Company (pending state approval of name change to Hartford Life Group Insurance Company ). Date L B REV 3/2004 5