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DISABILITY CLAIMS
- Use claim form C103 for filing your first disability claim.
- Use claim form C106 for filing a continuing disability claim.
- Complete the page of form C103 entitled "Employee – Initial Disability Claim Form". Please be sure to date and sign the blanks provided at the bottom of the form.
- Your employer should complete the page of form C103 entitled "Employer - Initial Claim Form".
- Your physician should complete the page of form C103 entitled "Physician - Initial Disability Claim Form".
- A copy of the police accident report is required for all accidents investigated by any law enforcement agency.
- Claims for ongoing disability will not be accepted more often than once per month. For continuing claim submissions, claim form C106 can be submitted. This form requires information from you and your physician only.
- Disability Income benefits may be subject to taxation. Please see Disability Income Benefits Subject to FICA Tax.
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DISABILITY INCOME – ACCIDENTAL DEATH AND DISMEMBERMENT RIDER CLAIMS
- Use claim form C101.
- Complete the section entitled "Claimant's Statement". Please be sure to date and sign the blanks provided at the bottom of the form.
- Submit a certified copy of the death certificate if the claim is for accidental death.
- If the claim is for dismemberment, the physician must complete PART B "Attending Physician's Statement" on the reverse side of claim form C101.
- A copy of the police accident report is required for all accidents investigated by any law enforcement agency.
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DISABILITY INCOME – EMERGENCY ACCIDENT RIDER CLAIMS
- Use claim form C101.
- Complete the section entitled "Claimant's Statement". Please be sure to date and sign in the blanks provided at the bottom of the form.
- Submit the statement from the physician or emergency room that shows the date of service, the diagnosis (ICD-9 codes), the procedures performed (CPT codes) and the itemized charges. The statement should show the name, address and tax identification number of the physician.
- A copy of the police accident report is required for all accidents investigated by any law enforcement agency.
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DISABILITY INCOME – FAMILY ACCIDENT BENEFIT RIDER CLAIMS
- Use claim form C101.
- Complete the section entitled "Claimant's Statement". Please be sure to date and sign in the blanks provided at the bottom of the form.
- Submit the statement from the physician or emergency room that shows the date of service, the diagnosis (ICD-9 codes), the procedures performed (CPT codes) and the itemized charges. The statement should show the name, address and tax identification number of the physician.
- A copy of the police accident report is required for all accidents investigated by any law enforcement agency.
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