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ShortTerm Disability (Fully Insured) Hartford Life Insurance CompanyHartford Life and Accident Insurance Company

SampleCompleted Short TermDisability Claim Form

Employers Statement

1. Date employee became insured underthis plan? This is usually the dayfollowing completion of the EligibilityWaiting Period for the group policy. Ifthe employee was a late enrollee,however, the effective date is the date theemployees Personal Health Statementwas approved by The Hartford.

2. Information needed for withholding andreporting taxes. This information isimportant because it determines theamount of taxable wages and/orbenefits that should be reported for theemployee. The portion of the benefitfunded by you is taxable.

3. Last day employee actually worked?This is the actual last day the employeeworked, not the date through whichearnings or sick pay were continued.

3

2

1

4. Information about the employeessalary. This information should bebased on the policys specific definitionof Weekly Earnings. If you recordearnings asan hourly rate, please besure to include the number of hoursworked in a regular week.

Employers Statement(Continued)

4

Employees Statement

5. Other Income Since the STD benefitrate may be affected by the amount ofother income benefits you receive or areeligible to receive, its important that youcomplete this section accurately.

5

Employees Statement(Continued)

Authorization to Obtain and Release Information

The employee completes and signs thissection.

Attending Physicians Statement

This statement is to be completed by thephysician who is treating the employee.

ShortTerm Disability (Fully Insured) Hartford Life Insurance CompanyHartford Life and Accident Insurance Company

SampleCompleted Short TermDisability Claim Form

Employers Statement

1. Date employee became insured underthis plan? This is usually the dayfollowing completion of the EligibilityWaiting Period for the group policy. Ifthe employee was a late enrollee,however, the effective date is the date theemployees Personal Health Statementwas approved by The Hartford.

2. Information needed for withholding andreporting taxes. This information isimportant because it determines theamount of taxable wages and/orbenefits that should be reported for theemployee. The portion of the benefitfunded by you is taxable.

3. Last day employee actually worked?This is the actual last day the employeeworked, not the date through whichearnings or sick pay were continued.

3

2

1

4. Information about the employeessalary. This information should bebased on the policys specific definitionof Weekly Earnings. If you recordearnings asan hourly rate, please besure to include the number of hoursworked in a regular week.

Employers Statement(Continued)

4

Employees Statement

5. Other Income Since the STD benefitrate may be affected by the amount ofother income benefits you receive or areeligible to receive, its important that youcomplete this section accurately.

5

Employees Statement(Continued)

Authorization to Obtain and Release Information

The employee completes and signs thissection.

Attending Physicians Statement

This statement is to be completed by thephysician who is treating the employee.

ApplicationforSTDIncomeBenefitsFI_lc5180test.pdfFormAnnotation

RESET FORM: name_full_ee: date_dob_ee: addr_full_ee: group_policy_number_er: addr_full_er: addr_division_ee: date_hired_ee: date_insured: hours_per_week_ee: scheduled_worday_ee: other_ee: enrolled_ltd_ee: date_ltd_effective_ee: basis_of_std_issuance_ee: insured_under_prior_std_ee: date_from_prior_std_ee: date_to_prior_std_ee: qualified_family_leave_ee: std_ltd_continue_ee: date_from_leave_of_absence_ee: taxable_std_ee: taxable_ltd_ee: permanant_job_ee: date_ldw: ldw_full_day: ldw_hours_ee: reason_for_leaving_ee: work_related_condition: workers_comp_claim: date_rtw: rtw_full_time_part_time: slry_rate_of_pay_ee: slry_continuance_ee: slry_wkly_amt_ee: slry_from_ee: slry_to_ee: workers_comp_payments_ee: workers_comp_wkly_amt_ee: workers_comp_from_ee: workers_comp_to_ee: job_activity_standing: job_activity_walking: job_activity_sitting: job_activity_balancing: job_activity_stooping: job_activity_kneeling: job_activity_crouching: job_activity_crawling: job_activity_reaching: job_activity_keyboard: job_activity_climbing: activity_frequency_standing: activity_frequency_walking: activity_frequency_sitting: activity_frequency_balancing: activity_frequency_stooping: activity_frequency_kneeling: activity_frequency_crouching: activity_frequency_crawling: activity_frequency_reaching: activity_frequency_keyboard: activity_frequency_climbing: job_activity_pushing: activity_descr_pushing: activity_frequency_pushing: activity_weight_pushing: job_activity_pulling: activity_descr_pulling: activity_frequency_pulling: activity_weight_pulling: job_activity_lifting: activity_descr_lifting: activity_frequency_lifting: activity_weight_lifting: job_activity_carrying: activity_descr_carrying: activity_frequency_carrying: activity_weight: activity_performed_sitting: activity_performed_hands1: activity_performed_hands1_percent: activity_performed_hands2: activity_performed_hands2_percent: activity_performed_hands3: activity_performed_hands3_percent: job_modifications: job_modifications_descr: job_assistance: job_assistance_descr: name_supervisor: supervisor_tiitle: name_last_ee: name_first_ee: name_mid_ee: ssn_ee: addr_street_ee1: addr_city: addr_state_ee: addr_zip_ee: phone_area_ee: phone_ee: date_dob_ee1: sex_ee: marital_status_ee: name_er: injury_descr_ee: date_soughttrtmnt: name_full_physician: addr_full_physician: injury_job_change: injury_job_change_descr: injury_unable_work1: recieving_workers_comp: receiving_state_disability: receiving_no_fault_disability: receiving_other: recieving_other_descr: recieving_policy_number: received_name_addr: recieved_name_addr2: recieved_wkly_amt: date_received_from: date_received_to: occupation_related_cond_ee: occupation_related_cond_descr_ee: workers_comp_claim_filed_ee: workers_comp_claim_filed_rsn_ee: ldw_full_day_ee: date_ldw_ee: ldw_full_day_details_ee: date_fdd_ee: worked_since_disability_date_ee: worked_since_details3_ee: return_to_work: date_rtw_pt_ee: date_rtw_ft_ee: tax_withholdings_ee: (3): (3)name_full_insured: date_dob_insured: ssn_insured: name_full_patient: ssn_patient: date_dob_patient: height_patient: weight_patient: condition_result_of_illness: condition_result_of_injury: condition_result_of_pregnancy: condition_result_of_mental: date_month_delivery: date_day_delivery: date_year_delivery: date_lmp: work_related_injury_patient: diagnosis_patient: icd9_patient: symptoms_patient: test1_patient: date_test1_patient: test1_results_patient: test2_patient: date_test2_patient: test2_results_patient: bp_systolic_patient: