EMPLOYEE CLAIM PACKAGE SHORT TERM DISABILITY

EMPLOYEE CLAIM PACKAGE SHORT TERM DISABILITY Disability Benefits are intended to replace a portion of your earnings during the period of time that you are unable to work due to an illness or injury. You are not automatically entitled to disability benefits. To qualify for disability benefits, you must submit satisfactory proof of Total Disability as defined in your Group Insurance Policy, complete the Elimination Period, and meet the terms and conditions detailed in your Group Insurance Policy. Please contact your employer or refer to your benefit booklet to confirm your Elimination Period. Please submit the completed form within five days of your last day worked to allow timely assessment and management of the claim. THE FOLLOWING INFORMATION IS REQUIRED BEFORE WE CAN PROCESS YOUR CLAIM: Declaration and Authorization for Release of Personal Information Your permission to obtain information is needed to help us assess and manage your disability claim. This authorization ensures the collection and use of your information is in accordance with privacy legislation. By signing this form, you permit First Canadian Insurance Corporation to exchange information with your doctor, your employer, other insurers and hospitals where you received treatment, subject to privacy legislation. Employee Statement Asks general information about you, your occupation and the nature of your disability for the purpose of assessing your claim. Please complete all questions on the form, and be sure to include your Company Name, Firm/Division Number, and your Certificate Number. Attending Physician Statement Please have your physician complete this form. Ensure your physician includes copies of any test results, chart notes, consultation report(s) (and referral letters), and all other additional information that may assist us with your claim. You are responsible for providing medical proof you are entitled to receive disability benefits. If your physician requests a fee for the completion of this form, it will be your responsibility. Employer Claim Package Ensure your employer completes and submits this information on your behalf. Canada Pension Plan (CPP) Disability Benefits If you have applied for CPP disability benefits, please include your Notice of Entitlement with this application. If you have not applied, we may require you to submit an application for CPP benefits. Worker s Compensation Benefits If your disability occurred at work, and you have coverage through your provincial Worker s Compensation Board, you need to file a Worker s Compensation claim. Even if you are eligible for provincial Worker s Compensation benefits, First Canadian still requires you to apply for disability benefits under your group benefits plan within the time limits outlined in your Group Insurance Policy. THE CLAIM PROCESS Request for Additional Information Once your initial claim forms have been reviewed, we may request additional information from you, your employer and/or your physician. In all cases, we will advise you when additional information is required. Claim Interview A representative may contact you to obtain additional information and clarification regarding your occupation, education, employment and/or medical history, and your current condition. The Decision We will notify you and your employer, in writing, as soon as we have reached a decision on your claim, and the reason(s) for our decision. Page 1 of 1

EMPLOYEE CLAIM STATEMENT SHORT TERM DISABILITY DECLARATION AND AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION Personal information we collect from you is kept in strict confidence and will be used to assess your claim and to administer the benefit plan. I declare the statements made in this Authorization, and in any personal or telephone interview concerning my claim(s) for disability benefits, are true and complete. I understand all such statements will be considered in determining my entitlement to benefits. I authorize: First Canadian Insurance Corporation (First Canadian), any healthcare or rehabilitation provider, my plan administrator, any insurance or reinsurance company, administrators of government benefits or other benefits programs, any person having knowledge of me or my health, other organizations, or service providers working with First Canadian to exchange my personal information, when relevant and necessary for the purpose of investigating and assessing my claim(s), administering coverage I may have with First Canadian and administering the group benefits plan. The parties to whom this information may be disclosed include any third party administrator acting on behalf of First Canadian. This may include performing an independent assessment. First Canadian to exchange my personal information with my employer, plan sponsor, or plan administrator when relevant for the purposes of discussing rehabilitation and return-to-work planning. First Canadian to disclose personal information about my claim(s) to an auditor authorized by my employer, plan sponsor, or their advisor, or by First Canadian for the purpose of auditing the assessment of claims. First Canadian to use my Social Insurance Number for income tax reporting purposes. I acknowledge personal information is needed to investigate and assess my claim(s), to administer coverage(s) administered by First Canadian and to administer the group benefits plan. I acknowledge my consent enables First Canadian to process my claim(s) and refusing to consent may result in delay or denial of my claim(s). This consent may be revoked by me at any time by sending a written instruction to First Canadian. Except for audit purposes, the authorizations shall remain valid for the duration of my claim for benefits or until otherwise revoked by me. I confirm a photocopy or electronic copy of this authorization shall be as valid as the original. I acknowledge more specific information about collection and use of my personal information can be found in the Privacy Policy section of www.firstcanadian.ca or from the administrator of my benefit program. Signature Print Name Date Page of 1

EMPLOYEE STATEMENT SHORT TERM DISABILITY Employee Information Company Name Firm/Division # Employee s Full Name Certificate # Home Mailing Address APARTMENT/STREET CITY/TOWN PROVINCE POSTAL CODE 1 Please provide a phone number and an alternate number where we can reach you during the day if we have any questions about your claim: ( ) q Home q Cell q Other ( ) q Home q Cell q Other Date of Birth (YYYY/MM/DD) Sex q Male q Female Do you consent to communication with First Canadian via email, including personal information? q Yes q No Email Address If your employer pays for all or any portion of your disability benefits coverage, the benefits payable under the plan may be subject to income tax. If this applies to you, please provide your Social Insurance Number for income tax reporting purposes: SIN Interview Arrangements Please indicate if there are any times or dates when a telephone interview (if required) about your claim would be most convenient for you. About your Illness or Injury When did your symptoms first appear? (YYYY/MM/DD) On what date did your first see a doctor? (YYYY/MM/DD) On what date did this illness or injury prevent you from working? (YYYY/MM/DD) Have you ever had the same or similar condition? q Yes q No If Yes, please explain and provide dates. 3 Is your injury work related? q Yes q No If Yes, please explain below and provide the decision letter from your provincial Worker s Compensation Board, if you have Worker s Compensation coverage. Page 3 of 1

EMPLOYEE STATEMENT SHORT TERM DISABILITY (CONTINUED) About your Illness or Injury (continued) Is your illness or injury due to an accident? q Yes q No If Yes, please explain below. Is your illness or injury due to a motor vehicle accident? q Yes q No If Yes, provide the following: Copy of the Motor Vehicle Accident Report Damage Repair Estimate Auto Insurer s Name and Claim Number Adjuster s Name and Telephone Number If your disability is the result of any type of accident, are you taking legal action against any other person or organization? q Yes q No If Yes, provide all contact information for your legal representative, and the date the legal action started. If a settlement has been reached, please attach a copy of the terms of the settlement. 3 What treatment are you presently receiving (prescriptions, dietary, advice from doctor, physiotherapy, etc)? Description of Treatment Provider Date(s) of Visit(s) Phone # of Provider Were you hospitalized? q Yes q No If Yes, provide the name of the hospital and date of hospitalization. Name of Hospital Hospitalization Dates Briefly describe your present illness or injury and generally how it affects your ability to work. Page 4 of 1

EMPLOYEE STATEMENT SHORT TERM DISABILITY (CONTINUED) About your Illness or Injury (continued) List the duties of your job that you are able to perform given your illness or injury. (Please attach extra sheets if required.) Describe the duties of your job you are unable to perform because of your illness or injury, and why. (Please attach extra sheets if required.) Job Duty That Can t be Performed Due to Illness or Injury Reason 3 Are you able to do any portion of your regular job? q Yes q No If Yes, please provide details. If No, what suggestions do you have to assist with an early and safe return to work? Are you presently working in any capacity (eg. self-employed or with a different employer)? q Yes q No If Yes, please provide details. Page 5 of 1

EMPLOYEE STATEMENT SHORT TERM DISABILITY (CONTINUED) Return to Work When do you expect you will be able to return to your own job? (YYYY/MM/DD) q Full Time q Part Time When do you expect to be able to do modified duties? (YYYY/MM/DD) q Full Time q Part Time Have you tried to return to work already? q Yes q No If Yes, from (YYYY/MM/DD) to (YYYY/MM/DD) Did you return to: q your own job q own job with modified duties q a different job 4 Did you return to: q Full Time hours q Part Time hours If you have not returned to work: Have you discussed a return to work with your employer? q Yes q No Have you discussed a return to work with your physician? q Yes q No If you have discussed a return to work, on what basis did you discuss returning? q to your own job q to your own job with modified duties q to a different job If you have discussed a return to work with your employer and/or physician, and have not yet returned to work, please provide details of your discussion(s) and the reason(s) you have not yet returned to work. 5 Other Income For the duration of your claim for benefits, it is your responsibility to notify First Canadian of: any work performed, whether or not you have received a wage or remuneration, or any employment income paid to you or any other person or party as a result of work performed by you. Have you applied for, or are you receiving the following: Applied Receiving Yes No Yes No $ Amount Canada Pension Plan/Quebec Pension Plan Benefits q q q q Worker s Compensation Benefits (or similar plan) q q q q Employment Insurance Benefits q q q q Automobile Insurance Benefits q q q q Any Other Disability Benefits Details q q q q Employer Sponsored Retirement/Pension Plan Income q q q q Self Employment Income or any Other Employment Income q q q q Any Other Income Details q q q q If you are receiving any of the above, please notify us immediately and supply copies of income and/or benefit statements. A retroactive award from another source may reduce your STD benefit and could result in an overpayment. If this occurs, you are responsible to reimburse any overpayment amounts to First Canadian. 6 Declaration I certify the information contained in this application is true, correct, and complete to the best of my knowledge. I understand all phone conversations with First Canadian Insurance Corporation representatives are recorded for quality assurance, training purposes, and dispute resolution. Employee Signature Date Page 6 of 1

EMPLOYEE STATEMENT SHORT TERM DISABILITY (CONTINUED) Authorization for Direct Deposit Complete this authorization, identifying the bank account you want to use to receive benefit payments directly from First Canadian Insurance Corporation. The account must have chequing privileges. Send this completed form to us, along with a sample cheque marked VOID. Without a sample cheque, we do not have the banking codes we need to make direct deposits on your behalf. Employee s Full Name Certificate # Company Name Firm/Division # Home Mailing Address APARTMENT/STREET CITY/TOWN PROVINCE POSTAL CODE I authorize First Canadian Insurance Corporation to deposit benefits payable to me to the account I have elected. I can cancel this authorization at any time by writing First Canadian Insurance Corporation. I have attached a sample cheque, marked VOID, to provide the banking details necessary for direct deposit. I understand that First Canadian will mail an Explanation of Benefits statement to me explaining how each direct deposit amount has been calculated. 7 Employee Signature Date PLEASE ATTACH A SAMPLE CHEQUE, MARKED VOID. Page 7 of 1

ATTENDING PHYSICIAN STATEMENT SHORT TERM DISABILITY Employee Identification (the Employee completes this section prior to appointment with physician) Company Name Firm/Division # Employee s Full Name Certificate # Home Mailing Address APARTMENT/STREET CITY/TOWN PROVINCE POSTAL CODE 1 Date of Birth (YYYY/MM/DD) I hereby authorize the release of medical and health information in my file to First Canadian Insurance Corporation (First Canadian) and any authorized advisors for the purpose of assessing my disability claim and administering the benefits plan. The parties to whom this information may be disclosed include any third party administrator acting on behalf of First Canadian. This medical and health information includes, but is not limited to, copies of all consultation reports, clinical notes, test results and hospital records. I understand I can revoke this consent at any time, but without it my claim cannot be assessed. I understand I am responsible for any fees related to the completion of this form. Employee Signature Date Attending Physician Statement (the Physician completes the remainder of the form) Please Note: Your detailed response will help us process your patient s disability claim more quickly. Your patient is responsible for any fee charged for completing forms. HISTORY Primary Diagnosis Secondary Diagnosis If Childbirth Expected or Actual Delivery Date (YYYY/MM/DD) Is this condition due to: q Occupational Illness/Injury? q Motor Vehicle Accident? Date of event (if applicable) (YYYY/MM/DD) ICD Code ICD Code Have you completed any other disability claim forms recently for this patient? q Yes q No If Yes, please indicate requestor: (other insurance company, CPP/QPP, Worker s Compensation) Date of patient s first visit to you pertaining to this condition (YYYY/MM/DD) First date your patient was absent from work due to this condition (YYYY/MM/DD) TREATMENT Please outline the treatment plan for this patient. Include any special programs, therapies and medications. Frequency of Visits q Weekly q Monthly q Other (describe) Date of Last Visit (YYYY/MM/DD) Has the patient been treated for this same or similar condition in the past? q Yes q No If Yes, date (YYYY/MM/DD) Is the patient following the recommended treatment program? q Yes q No Please elaborate. Page 8 of 1

ATTENDING PHYSICIAN STATEMENT SHORT TERM DISABILITY (CONTINUED) RESPONSE TO TREATMENT Please describe the response to treatment to date. q Complete q Partial q None q Too soon to tell Are there any plans to change or alter the current treatment program? q Yes q No If Yes, please explain. If your patient is not improving with the current treatment plan, please outline any factors that may be contributing to the poor response as well as proposed plan to address these factors. HOSPITALIZATION Is/was the patient hospitalized? q Yes q No Is future hospitalization planned? q Yes q No Date of admittance (YYYY/MM/DD) Date of Discharge (YYYY/MM/DD) Institution Name 1.. 3. If surgery and or medical procedure was/will be performed, please provide date(s) and description of surgery(ies) and/or procedure(s): Date (YYYY/MM/DD) 1.. Description INVESTIGATIONS Are tests/investigations pending? q Yes q No Date (YYYY/MM/DD) 1.. Please attach copies of all relevant: Test results/investigations (If not attached, we will interpret this as tests were not performed) Consultation reports and all referral letters Chart notes Description If consultation report(s) not attached, will the patient be seen by a specialist(s) for this condition in the future? q Yes (attach referral letter) q No Name of Specialist Specialty Date (YYYY/MM/DD) 1. Important: Page 9 of 1

ATTENDING PHYSICIAN STATEMENT SHORT TERM DISABILITY (CONTINUED) CLINICAL FINDINGS AND OBSERVATIONS Dominant Hand q Left q Right Height q ft/in q cm Weight q lbs q kg Please describe the patient s symptoms including history, severity and frequency. How have the patient s symptoms evolved to date? q Improved q No Change q Retrogressed RESTRICTIONS AND LIMITATIONS Based on your clinical findings and observations, please describe the patient s current cognitive and/or physical restrictions and limitations. Has any license held by the patient been restricted or revoked as a result of this condition? q Yes q No If Yes, as of when? (YYYY/MM/DD) Type of License Do you have concerns about the patient s ability to manage his/her own affairs? q Yes q No Are there any non-medical factors that may impact the patient s expected recovery and return-to-work goals? q Yes q No If Yes, please elaborate. Page 10 of 1

ATTENDING PHYSICIAN STATEMENT SHORT TERM DISABILITY (CONTINUED) PROGNOSIS Please provide the patient s prognosis for improvement and/or recovery. RETURN TO WORK Do you expect the patient will return to pre-disability level of function? q Yes q No If No, please provide details. Has return to work been discussed with the patient? q Yes q No If No, please provide details. If Yes, please provide the expected date of return to: Part Time Hours (YYYY/MM/DD) Please detail return to work discussions. Modified Duties (YYYY/MM/DD) Full time, regular duties (YYYY/MM/DD) Page 11 of 1

ATTENDING PHYSICIAN STATEMENT SHORT TERM DISABILITY (CONTINUED) RETURN TO WORK (CONTINUED) We work collaboratively with all workplace parties to develop safe and sustainable Return to Work programs for injured or ill employees. Please identify any limitations which may apply while your patient is participating in a Return to Work program. For each limitation, briefly describe it on the line below the given work demand. Sitting Standing Walking Lifting Climbing Driving Twisting Reaching Crouching Gripping Bending Push/Pull Attention/Concentration Memory Fatigue Other (provide details) Please comment on your patient s willingness to return to work. Please provide any other information you may feel is relevant to this claim. Physician Name Specialty 3 Address Phone ( ) Fax ( ) Physician Signature Date Page 1 of 1