Short Term Disability (DOC)

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					                                                              P.O. Box 2272
Short Term Disability                                         Seattle, WA 98111-2272
                                                              Phone: (425) 918-4575 or (800) 258-0394
Claim Application                                             Fax: (425) 918-4485 or (800) 628-2380
                                                              www.lifewiseac.com
                                                              email: claims@lifewiseac.com




To file an application for Short Term Disability benefits, please follow the instructions below to avoid unnecessary delays.
You can also initiate a claim by phone: Call 800-258-0394 and press 2.
Any cost for completion of this form will be at the insured’s expense.
This form requests information that is necessary to the speedy and accurate administration of your claim. If the claim
form is not completed in full, determination of benefits will be delayed until all required information has been received. If
a question does not apply, or information is not available, please write “NA” (not applicable) in those spaces.
Please note: We cannot process your claim unless the Authorization for Release of Information (page 2) is signed by you
and submitted to LifeWise Assurance Company.


There are four (4) primary sections to be completed in this form:

      Section 1: Authorization and Disclosure
                   You (the employee) must fully complete the “Authorization” on page 2. This will allow us to
                   secure additional information (if necessary) to make a decision on your claim. We cannot
                   process the claim if this is not completed.

      Section 2: Employee’s Statement
                   Fully complete the section “To Be Completed by Employee” on page 3.

      Section 3: Employer’s Statement
                   Have the employer fully complete the section “To Be Completed by Employer” on page 4.

      Section 4: Physician’s Statement
                   Have the attending physician complete the section “To Be Completed by Physician” on page 5.
                   Please complete the top line with your name, date of birth and social security number before
                   giving the form to your physician.




When ALL sections of this form have been completed, please send it to us at the above address by mail or fax.




It is the responsibility of you and your employer to inform us of any scheduled or actual return to work date as
soon as possible.




If an overpayment should occur on your claim, the amount of the overpayment must be returned to us.




                                                                                            A member of the Premera family of companies
000795 (02-2012)                                           Page 1
                                                                   P.O. Box 2272
Authorization and Disclosures                                      Seattle, WA 98111-2272
                                                                   Phone: (425) 918-4575 or (800) 258-0394
                                                                   Fax: (425) 918-4485 or (800) 628-2380
                                                                   www.lifewiseac.com
                                                                   email: claims@lifewiseac.com



    Section 1: To Be Completed by Employee (please complete in blue or black ink only)


The following authorization will be used to obtain additional information (if necessary) concerning this claim.


                                     Authorization for Release of Information
Persons or institutions: This authorizes you to give LifeWise Assurance Company, its reinsurers, representatives, or persons performing
business or legal services on behalf of LifeWise Assurance Company any information, data or records you have regarding my medical
history and treatment (including records pertaining to psychiatric, drug or alcohol use, and any medical condition I may now have or have
had), and any information, data or records regarding my Social Security, FICA earnings history, Workers’ Compensation, state disability,
pension, credit, financial, earnings and employment history needed to evaluate my claim for disability benefits.

I understand that any information obtained pursuant to this authorization will be used only to evaluate my claim and may be transferred to
any organization or person employed by or representing LifeWise Assurance Company to assist with this purpose. Unless I revoke it, this
authorization is valid during the pendency of my claim but not longer than 24 months. I understand that I have the right to revoke this
authorization and request and receive a copy of this authorization. A photocopy of this authorization is as valid as the original.

I further understand that I may change my mind and revoke this release at any time. I will do this by letting LifeW ise Assurance Company
know of my decision. Any change will be effective five (5) business days after LifeWise Assurance Company receives my written notice at
the address listed at the top of this form. I understand that some or all of this information may already have been shared and that LifeWise
Assurance Company will not be liable for any information already released.



Group Name                                                              Group Policy Number


Name (please print)                                                     Street Address


Signature                                                                                                     Date
X
Fraud Statements:
Arizona: Any life insurance producer, examining physician or other person who knowingly makes a false or fraudulent statement or
representation on or relative to an application for life or disability insurance, or who makes any such statement to obtain a fee,
commission, money or benefit is guilty of a Class 2 misdemeanor.
California: 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.
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.
New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
Washington: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
All other states: Any person who knowingly and with intent to defraud or deceive any insurance company submits an insurance
application or statement of claim containing any false, incomplete or misleading information may be subject to civil or criminal
penalties, depending upon state law.
.




                                                                                                 A member of the Premera family of companies
000795 (02-2012)                                               Page 2
                                                                                      P.O. Box 2272
Short Term Disability                                                                 Seattle, WA 98111-2272
                                                                                      Phone: (425) 918-4575 or (800) 258-0394
Employee’s Statement                                                                  Fax: (425) 918-4485 or (800) 628-2380
                                                                                      www.lifewiseac.com
                                                                                      email: claims@lifewiseac.com



  Section 2: To Be Completed by Employee (Please Print)

If claim form is not completed in full, determination of benefits will be delayed until all required information has been received. Write “NA” in non-applicable sections.
1 Employee Name                                                                                                                 2 Social Security No.

    Street/Box/Apartment                                                                                                        3 Phone No. (               )

    City, State, ZIP                                                                                 4 E-mail Address
5 Address you want your check mailed to, if different than above

6 Height                          7 Weight                           8      Male          Female           9 Date of Birth                /             /
10 Employer Name                  11 Occupation                      12 List Occupation Duties

13 Date of accident or date of first symptoms                        14 Last day worked             15 Are you unable to work due to? (check one)
             /          /                                                                                  Injury        Illness      Pregnancy
16 Date you returned to work                                                     17 If you have not returned to work, when do you expect to return?
          /            /                       Full Time         Part Time                      /        /                       Full Time        Part Time
18 Describe in detail, when, where and how accident occurred, or nature of disability and first symptoms

19 Is your accident or illness related to your occupation?       Yes        No      20 If yes, have you filed a Workers’ Compensation Claim?      Yes         No
   If Yes, please explain:                                                             If No, do you intend to?       Yes      No
                                                                                       If No, please explain:
                                                                                       If Workers’ Compensation has been denied, submit copy of denial with this claim.
21 Describe limitations that keep you from working

22 List any medications you are taking

23 When were you first treated for your illness or accident?
   Hospital                                                               Address                                                             Date(s)

    Doctor                                                                Address                                                             Date(s)

24 Have you had the same or similar condition in the past?          Yes       No      If Yes, list name and address of Hospital/Doctor:
   Hospital                                                               Address                                                             Date(s)

    Doctor                                                                Address                                                             Date(s)

25 Are you receiving?
(check those benefits you are receiving due to your disability)                                                              Amounts received because of your disability
        Workers’ Compensation Amount           $                          State Disability Amount         $                      Social Security
        Employer Sick Leave / PTO Amount $                                Other Amount                    $                          Insured        $
        Auto Ins. Wage Replacement Amount $                                Specify Source                                            Spouse         $
    If Yes, give name and address of insurer and date benefits began and ended                                                       Dep. Children $
    Auto Insurer Name                                                  Address                                                           Begin date       End date

26 If benefits are approved, do you want the minimum $20.00 per week withheld from your check for Federal Income Tax purposes?                   Yes        No
   If you want more withheld, please state dollar amount you want withheld $



The above statements are true and complete to the best of my knowledge and belief. Your signature is required for benefit consideration.



Signature   X                                                                                                                        Date


                                                                                                                       A member of the Premera family of companies
000795 (01-2012)                                                            Page 3
                                                                                     P.O. Box 2272
Short Term Disability                                                                Seattle, WA 98111-2272
                                                                                     Phone: (425) 918-4575 or (800) 258-0394
Employer’s Statement                                                                 Fax: (425) 918-4485 or (800) 628-2380
                                                                                     www.lifewiseac.com
                                                                                     email: claims@lifewiseac.com


  Section 3: To Be Completed by Employer (Please Print)

If claim form is not completed in full, determination of benefits will be delayed until all required information has been received. Write “NA” in non-applicable sections.
1 Employee Name                                                                                               2 Social Security No.

    Street/Box/Apartment                                                                                      3 Date of Birth

    City, State, ZIP                                                                                          4 Regulatory Scheduled Hours per Week

5 Date of Hire                                 6 STD Insurance Effective Date                                         7 Employee’s Occupation
8 Policy No.                                               9 Policy Division No.                                      10 Policy Class
11 Employee’s Work Schedule             Full Time        Part Time        Exempt           Non-Exempt            Seasonal
12 Check Regular Workdays            Sun         Mon           Tues     Wed         Thurs           Fri       Sat       Varies
13 Was employee actively working when disability began                  Yes         No
     If “No”, reason (check one box)
        Terminated          Leave of Absence        Laid Off               Sick Leave                 Vacation                 Resignation                  Other (specify)
    Date employee ceased active work
14 Date Last Worked                                                                         15 Hours Worked That Day
16 How was employee paid? (check appropriate box)              17 Frequency of pay? (check appropriate box) 18 Annual Salary $
        Hourly (non-exempt)                                           Weekly                                                Includes:
        Salaried (exempt)                                             Bi-weekly                                                Commissions            Bonuses             Overtime
                                                                      Monthly                                                  Extra Compensation (explain)
19 Date Last Salary Increase                        20 Employee Work Schedule at Time Last Worked
                                                       Days per Week                          Hours per Week                                 Hourly Wage $
21 How long has employee been in this job?          22 Has Employee Returned to Work?          Yes       No
                                                       If Yes, Date:                  Full-Time         Part-Time
23 Date Paid Through                       for         Vacation          Sick Pay           PTO               Other
24 Does employee contribute toward the STD premium?            Yes         No If employee contributes, submit a copy of employee’s last pay stub.
   If Yes,     Pre-tax      Post-tax                    % paid by employee                % paid by employer
25 Should Social Security and/or Medicare taxes be withheld? Social Security?         Yes       No    Medicare?        Yes       No
26 Employee is eligible for                      If Yes, Weekly or                                                                      Date Benefits                         (MM/DD/YYYY)
                                  Yes No         Monthly Amount           Wk Mo                    Provider Name/Address                    Begin                              Through
   Salary Continuation                           $
   Disability Pension                            $
   Retirement Pension                            $
   State Disability                              $
   Social Security                               $
   Workers’ Compensation                         $
   Has Workers’ Comp
                                              If Workers’ Compensation has been denied, submit copy of denial with this claim.
   Claim been filed?
27 Does your company have a rehire or return to work policy for disabled employees?         Yes        No
   What is the name of the person we should contact if we identify a return to work option?
28 Name/Address of the employee’s medical insurance carrier or HMO (provide policy or ID No.)

29 Employer Name                                                                            Phone Number                                     Fax Number
                                                                                            (             )                                  (          )
    Address                                                                                 City                                             State                     ZIP

    Print name of person completing this form                                               Title                                            E-mail

    Signature (The above statements are true and complete to the best of my knowledge)                                                       Date
    X

                                                                                                                                 A member of the Premera family of companies
000795 (02-2012)                                                                  Page 4
                                                                                            P.O. Box 2272
Short Term Disability                                                                       Seattle, WA 98111-2272
                                                                                            Phone: (425) 918-4575 or (800) 258-0394
Physician’s Statement                                                                       Fax: (425) 918-4485 or (800) 628-2380
                                                                                            www.lifewiseac.com
          gd
                                                                                            email: claims@lifewiseac.com


 Section 4: To Be Completed by Physician (Please Print)
If claim form is not completed in full, determination of benefits will be delayed until all required information has been received. Write “NA” in non-applicable sections.
                                                    Any cost for completion of this form will be at the insured’s expense.
Patient Name                                                                                         Date of Birth                          Social Security No.

Height                Weight

1 Patient is/was unable to work (check one)          Full time           Part time due to : (check one)           Injury        Illness       Pregnancy as of             ______ date
2 Diagnosis (included complications and ICD 9)


                                         Complete this section for Normal Pregnancy, then go to item 27
If disabled date is greater than two weeks before expected date of confinement complete lines 17, 18, 19, 21, 22 & 23.
3 What was LMP date?                                  4 What is the             expected or          actual date of delivery?     5 Date you advised the patient to stop working

6 Expected length of postpartum recovery              7           Vaginal delivery               planned                     8 Date First Treated                 9 Date Last Treated
                                                                  Cesarean delivery              actual
                                 Complete the following items for all conditions except Normal Pregnancy
10 When did symptoms first appear or accident happen?                                     11 Is condition due to injury or illness arising out of patient’s employment?
                                                                                                  Yes         No
12 Has patient ever had same or similar condition?               Yes           No                                                           13 Is this an
   If yes, state when and describe                                                                                                                  illness?       Injury?
14 Date of First Visit                                             15 Date of Last Visit                                                    16 Frequency of Visits

17 Objective findings (X-rays, EKGs, lab data and clinical findings)                             18 Subjective Symptoms

19 Nature of treatment (type of surgery, name of medications, etc.)

20 Names and addresses of other physicians

21 Has patient been hospitalized?        Yes          No                                             If Yes, give name and address
   From                              to
22 Restrictions (what the patient SHOULD NOT do)                                                 23 Limitations (what the patient CAN NOT do)

24 Mental impairment (if applicable) Provide 5 AXIS Diagnosis
     I.                                                          III.                                                                  V.
    II.                                                      IV.
25 If this is a cardiac condition, what is the functional capacity?                  Class 1—No Limitation                 Class 3—Marked Limitation
   (American Heart Association)                                                      Class 2—Slight Limitation             Class 4—Complete Limitation
26 Has maximum medical improvement been achieved?                       Yes          No       If No, when do you expect a fundamental change?
    When is next scheduled appointment                                                            1― 2 weeks               3― 4 weeks             5― 6 weeks             more than 6 weeks
27 When is patient released to return to work?                                       Part time                             Full time
                                                                                     With no restrictions                  With restrictions (see box 22 & box 23)
28 Physician’s name (Please Print)                                                               Degree                                            E-mail

    Specialty                                                                                    Phone No.                                         Fax No.
                                                                                                 (           )                                      (        )
    Address                                                                                      City                                              State                   ZIP

    Signature (No Stamp)                                                                         Tax ID number                                     Date
    X
                                                                                                                                       A member of the Premera family of companies
000795 (02-2012)                                                                     Page 5

				
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