1. FULL NAME (LAST, FIRST) SOCIAL SECURITY NUMBER:
2. ADDRESS CITY STATE ZIP CODE PHONE NUMBER:
3. DATE OF BIRTH HEIGHT WEIGHT SEX: MALE 4.OCCUPATION (LIST THE DUTIES AT THE TIME OF DISABILITY) FEMALE
5. MARITAL STATUS : SPOUSE'S DOB IS SPOUSE EMPLOYED?
YES NO
6. NO. OF CHILDREN CHILDREN'S FIRST NAMES AND DATES OF BIRTH
7. I HAVE BEEN UNABLE TO WORK BECAUSE OF I RETURNED TO WORK ON A PART TIME BASIS I RETURNED TO WORK ON FULL THIS DISABILITY SINCE: (MO-DAY-YR) SINCE: (MO-DAY-YR) TIME BASIS: (MO-DAY-YR)
8. DATE OF ACCIDENT OR DATE YOU FIRST IS YOUR ACCIDENT OR ILLNES RELATED TO IF YES, EXPLAIN. NOTICED THE SYMPTOMS OF YOUR ILLNESS. YOUR OCCUPATION?
YES NO
9. DESCRIBE HOW AND WHERE ACCIDENT OCCURRIED OR DESCRIBE THE FIRST SYMPTOMS OF YOUR ILLNES.
10. DATE YOU WERE FIRST TREATED FOR TREATED BY: YOUR ILLNESS OR INJURY (MO-DAY-YR) HOSPITAL:
DOCTOR: 11. HAVE YOU EVER HAD THE SAME OR SIMILAR TREATED BY: CONDITION IN THE PAST? YES HOSPITAL IF YES, WHEN? (MO-DAY-YR)
DOCTOR
12. DESCRIBE ANY OTHER INCOME YOU ARE RECEIVING OR ARE ELIGIBLE TO RECEIVE AS A RESULT OF YOUR DISABILITY (EXAMPLES: SOCIAL SECURITY, WORKERS COMPENSATION; STATE DISABILITY; PENSION DISABILITY, ETC.)
DESCRIBE SOURCE AMOUNT OF INCOME DATE INCOME BEGAN ENDED
The above Statements are true and complete to the best of my knowledge and belief.
DATE
ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND FOR OCCURRENCES IN THE STATE OF NEW YORK, SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND IN THE STATE OF NEW YORK, SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED
SIGNATURE
EMPLOYEE STATEMENT
(To Avoid Delay Please Answer ALL Questions)
FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
AS REQUIRED BY LAW, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR A STATEMENT OF CLAIM CONTAINING ANY FALSE INFORMATION, OR CONCEALS FOR THEPURPOSE OF MISLEADING, INFORMATION CONCERNING
THE UNITED STATES LIFE Insurance Company
An American General Company
3600 Route 66 - PO Box 1580 - Neptune NJ 07754 1580 - 732 922 7000
AUTHORIZATION FOR RELEASE OF INFORMATION (HIPAA COMPLIANT)
I authorize any doctor, medical institution, insurance or reinsuring company, police enforcement and/or employer, to give any and all information requested by and to the City Employees Club of Los Angeles, or to its legal representative. I understand that the information obtained by this authorization will be used only to assist me in the processing of my claim.
This authorization includes police reports and the explanation of the status of the claim, the decisions the insurance made on my claim, the benefits paid, the end of the benefits and any information requested by the City Employees Club of Los Angeles necessary to support me in processing my claim.
This authorization is valid during the pendency of my claim, including the appealing period, and shall expire on the date my claim finally ends to my satisfaction.
I understand that my authorized representative or I have the right to request and receive a copy of this authorization. I also understand that I have the right to revoke this authorization by notifying the City Employees Club of Los Angeles in writing.
A photocopy of this authorization is as valid as the original.
Claimant Name: __________________________________ Date of Birth: ______/______/_______
DAYS PER WK: YES NO TEL: AMOUNT:
HRS. PER DAY: DURATION:
HRLY RATE:
3
MONTHS PRIOR DISABILITY BASIC MO. EARNINGS: 3 MONTHS:2 MONTHS: WORKER's COMP
1 MONTH:
POLICY NO.: V209,282
PERCENTAGE INS. EFF. DATE:
100% DEPT: 75% TEL: 50% FAX: NAME: PERCENTAGE DATE: SIGNATURE: TITLE: DEPT: PERCENTAGE STARTS ENDS TEL:
FAX: DATE: NAME:
Any Raises? SIGNATURE:
Any Changes? TITLE:
Please, FAX this form to: 213 620 0598
Questions? 213 620 6983
DATE ENDS TOTAL AMOUNT
THE UNITED STATES LIFE Insurance Company
An American General Company
3600 Route 66 - PO Box 1580 - Neptune NJ 07754 1580 - 732 922 7000
APPLICATION FOR LONG TERM DISABILITY BENEFITS CITY
(To Avoid Delay Please Answer ALL Questions)
EMPLOYER STATEMENT
AS REQUIRED BY LAW, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR A STATEMENT OF CLAIM CONTAINING ANY FALSE INFORMATION, OR CONCEALS FOR THEPURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND FOR OCCURRENCES IN THE STATE OF NEW YORK, SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND IN THE STATE OF NEW YORK, SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
INFORMATION ABOUT EMPLOYEE AND SALARY:
1. EMPLOYEE'S NAME: SOCIAL SECURITY NUMBER: EMPLOYEE'S DATE OF HIRE:
2. LAST DAY WORKED: REASON FOR STOPPING WORK: RETURNED TO WORK: OCCUPATION AT TIME OF DISABILITY: 3. SCHEDULE AT TIME OF DISABILITY: IS EMPLOYEE ELIGIBLE FOR W COMP? IS EMPLOYEE ELIGIBLE FOR PENSION?
WC Examiner:
6. HAS EMPLOYEE FILED A CLAIM FOR: 4. BASIC MONTHLY EARNINGS:
Disability Benefits provided by Employer State Mandated Ben Union Welfare
Unemployment
INFORMATION ABOUT SCHEDULE OF BENEFITS INFORMATION ABOUT DISABILITY INS.:
SICK TIME (PAYROLL OFFICE) V209,281
DATE STARTS DATE ENDS TOTAL AMOUNT
E-mail address: [email protected]
IOD (PAYROLL OFFICE)
WORKERS COMPENSATION WORKERS COMP.
