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Claim form help

Disability claim forms are available by contacting a Disability Benefit Center

The LTD claim form has three sections. The employer contact, claimant and attending physician each should complete their respective portions.

  • Employer Claim Statement - This should be completed by an authorized representative of the policyholder (who is someone other than the claimant).
  • Claimant Statement - This should be completed by the claimant, or by someone on his/her behalf if the claimant is mentally or physically unable to do so. If someone other than the claimant signs the claim statement, it may be necessary to obtain guardianship documents.
  • Attending Physician's Initial Statement of Disability - This should be completed by the physician or physicians who treated the claimant from the onset of the disabling condition for which claim is being made.

Each form should be completed in its entirety with as much detail as possible. If any party feels that a question needs a more extensive answer, a separate statement can be used to fully explain. All claims are administered with the contract provisions that were in effect as of the date the claimant became disabled.

Additional help:

Employer Claim Statement - Part 1

Step

Description

1.-9.

Self-explanatory.

10.

The date claimant was originally covered by the Assurant Employee Benefits policy. If there has been a lapse of coverage at some point since the original effective date, this should be noted by giving the original date of coverage, lapse date, and date claimant became covered again. If claimant has increased the amount of his coverage since the original date of coverage, we need to know the original date of coverage and the date the increase in coverage was effective.

11.

The last day the claimant actually worked at his/her regular occupation, and the total number of hours worked that day.

12.

Claimant's work schedule prior to his/her disability.

13.

This question should be completed if your group had LTD coverage through a different carrier immediately prior to your Assurant Employee Benefits' coverage. If applicable, provide us with the claimant's effective and termination dates under the prior plan.

14.

For example, Life, Medical, Dental, etc.

16.-17.

If the claimant has returned to work, advise us of his/her current work schedule.

18.

Advise us of the outcome of your discussion(s) with the claimant, and if any reasonable accommodations were able to be made to allow the claimant to return to work.

19.

The claimant's basic monthly earnings as of the determination date indicated in your LTD policy. If the claimant receives any bonuses, commissions or other unusual compensation, review the Policy Definition of Monthly Earnings and provide supporting documentation.

20.-.22

LTD benefits may be taxable. These questions are essential for us to make that determination.

23.

Self-explanatory.

24.

For any source of income marked, please attach payroll records, award notices, denial notices or any other available documentation.

25.

Self-explanatory.

26.

This portion of the claim statement must be signed by someone other than the claimant who is filing the claim. Be sure to indicate the title or position of the person signing the form.

Employer Claim Statement - Part 2

Fully complete this section of the claim statement for all claims.

Attach a copy of the employer's own description of the claimant's position to this claim statement. If a job description is not available, please attach a separate sheet describing the nature of the essential duties of the claimant's position. Someone who is familiar with the claimant's position, e.g.: a supervisor, should complete this section.

Step

Description

1.

Self-explanatory.

2.

Please tell us how often the claimant does each of the activities listed and the amount(s) of weight, if any, the claimant is required to lift and carry in a typical workday.

3-5.

Self-explanatory.

Claimant Statement

If the claimant has returned to work (at his/her regular occupation) or if the claim is for pregnancy, Part 2 of the Claimant Statement does not need to be completed.

Authorizations
It is very important that the claimant sign and date both authorizations (pages 7 and 8).

Union Security Insurance Company does not disclose any personal, financial or health information unless otherwise permitted by law.  If you would like more information, you may obtain a copy of our Privacy Notice by contacting us at Union Security Insurance Company, Attention: Privacy Officer, P.O. Box 419052, Kansas City, MO 64141-6052.

Attending Physician's Initial Statement of Disability

Primarily, we are looking for the physician(s) who rendered treatment at the onset of disability. However, the physician most familiar with the claimant's condition and limitations, if different, should complete a claim form.

If multiple physicians are seeing the claimant, or if another physician was treating the claimant when he/she first quit working, the Attending Physician's Initial Statement of Disability may be photocopied and multiple forms submitted. At a minimum, other treating physicians should be noted on the Physician Statement or a list with phone numbers attached