Microsoft Word EFN 1327.doc

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1 IMPORTANT INFORMATION REGARDING APPLICATION FOR BENEFITS This form is to be attached to the proof of Loss Claim Statement when a claim is submitted to First Reliance Standard Life. Please be sure that all responsible parties completing and filing a claim for benefits are aware of the following statements which concern claim fraud and abuse: 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 fines and confinement in prison. State of California For your protection, California law requires the following to appear on this form: Any person nt of a loss is guilty of a crime who knowingly presents a false or fraudulent claim for the payme and may be subject to fines and confinement in state prison. State of Florida Any person who knowingly and with intent to injure, defraud, or deceive any insurer, files a statement of claim or an application containing false, incomplete or misleading information is guilty of a felony of the third degree. State of New Jersey Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. State of New York Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false on concerning any fact material information, or conceals for the purpose of misleading, informati thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. State of Ohio rson who, with intent to defraud or knowing that he is facilitating a fraud against an Any pe insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. State of Oregon Any person who, with an intent to knowingly defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, may be subject to prosecution for insurance fraud. State of Pennsylvania Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. EFN -1205

2 New York Disability Benefit Law Short Term Disability Benefits Initial Statement of Claim HOW TO FILE A CLAIM Please follow the instructions listed below to avoid unnecessary delays in processing your claim. This form must be fully fully completed, the processing of the claim may be delayed. completed for each disability claim. If the claim form is not 1) Complete and sign Part I answering all questions; and Employee 2) Complete and sign the AUTHORIZATION FO R USE IN OBTAINING INFORMATION form; and 3) Have your medical provider complete and sign the MEDICA L PROVIDER STATEMENT (Part III). Employer 1) Complete and sign Part II answering all questions. When all sections of this form have been completed submit the claim to: Reliance Standard Life Insurance Company P.O. Box 7749 Philadelphia, PA 19101-7749 (800) 351-7500 or You May F ax to: (267) 256-3519 PART I FOR EMPLOYEE TO COMPLETE Employee's Name Last First Middle Initial Employee's Birth Date Employee 's Social Security No. Sex  Male  Female Employee's Address (Street, City, State, Zip) Employee’s Occupation Yes  Is this claim based Did injury occur at work? I f "Yes," for whom were you working?  on an accident?  Yes No  No Last day worked Did you work a full day? Date you were first unable to work  Yes because of this disability No  Date of Accident How and where did accident happen? Time  AM  PM Give name of last employer. If more than one employer during the last eight (8) weeks, name all employers. AVERAGE WEEKLY WAGES DATES OF EMPLOYERS (Include Bonuses, Tips, EMPLOYMENT Commissions, Reasonable Value of Board, Rent, etc.) ADDRESS TELEPHONE NO. FROM THROUGH BUSINESS NAME BUSINESS Mo. Day Yr Mo. Day Y r. Are you now receiving or eligible to receive nd address of insurer, amount of  Yes  No If "Yes" give name a State Disability No income, date benefits began and ended. as a result of this disability: No Fault Disability  Yes  No Other _________ No  Social Security  Yes  Yes  Worker's Compensation  No Yes  I have received disability benefits for another period or periods of disability within the 52 weeks immediately before my prese nt disability  Yes  No began. From To If "Yes", fill in the following: I have been paid by Date Date Name and Address of Medical Provider Are you now receiving Unemployment Date you returned to work  Yes Compensation benefits?  No Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Telephone Number Date Employee's Signature ( ) SI TIENE DUDAD REPLACIONADAS CON LA RECLAMACION DE IF YOU HAVE ANY QUESTIONS ABOUT CLAIMING DISABILITY OFFICE OF THE NYS WORKERS' BENEFICIOS POR INCAPACIDAD, COMUNIQUESE CON LA OFICINA BENEFITS, CONTACT THE NEAREST COMPENSATION BOARD,OR WRITE TO: WORKERS' COMPENSATION MAS CERCANA DE LA JUNTA DE COMPENSACION OBRERA DE BOARD, DISABILITY BENEFITS BUREAU, 100 BROADWAY-MENANDS, NUEVA YORK O ESCRIBA A: WORKERS' COMPENSATION BOARD, ALBANY, NY 12241-0005 DISABILITY BENEFITS BUREAU, 100 BROADWAY-MENANDS, ALBANY, NY 12241-0005 First Reliance Standard Life Insurance Company, P.O. Box 7749, Philadelphia, PA 19101-7749 EFN-1327

3 AUTHORIZATION FOR USE IN OBTAINING INFORMATION NAME OF INSURED: ___________ ______________________________________ INSURED’S DATE OF BIRTH: ____________________________________________ POLICYHOLDER:___________________ ___________________________________ To all physicians and other health care pr ofessionals, hospitals, other health care institutions, insurers, medical, hospital and prepaid health plans, pharmacies, pharmacy benefit managers, employers, group policyholders, contract hol ders, governmental agencies (including but not limited to the Internal Revenue Service and the Social Security Administration), private and/or public benefit plan administrators, and/or attorney representatives, including but not limited to covered entities and business associates under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the accompanying regulations: You are authorized to provide First Reliance Standard Life Insurance Company and/or its authorized administrators, including but not limited to Matrix Absence Management, with and/or treatment provided to me, the above information concerning medical care, advice, named Insured, and/or any or benefit-related information employment, salary, tax and/ concerning me, the above named Insured. I understand that the disclosure of information may include disclosure of protected heal th information under HIPAA and the accompanying regulations, information regardi ng treatment for mental illness, the human immunodeficiency virus (HIV) and/or the use of drugs and alcoho l. I also understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and will no lon ger be subject to protection under HIPAA and the accompanying regulations. A statement of First Reliance Standard Life Insurance www.rsli.com Company’s privacy policy is available at or upon request. ormation will be used for t he purpose of evaluating my I understand that any such inf claim for benefits. Upon request, I understand that I am entitled to receive a copy of this Authorization. This Authorization is valid from the date signed for the duration of the claim but not longer than 24 months, and may be revoked by me at any time upon written request to the address below. A reproduction of this Authorization shall be considered as valid as the original. _________________________ _______________________________ Date Insured’s Signature (If the Insured is unable to sign, an authorized person may sign.) __________________________ ________________________________ Authorized Person’s Signature Date hority to sign on behalf of Insured: Description of Authorized Person’s aut ________________________________________________________________ First Reliance Standard Life Insurance Company, P.O. Box 7749, Philadelphia, PA 19101-7749 EFN-1327

4 PART II FOR EMPLOYER TO COMPLETE STD Policy No. Employee's Name Social Security No. DBL Policy No. Job Title ent Card Signed Effectiv e Date of Insurance Insurance Class Hire Date Date Enrollm ed to Work Date Retired (If Applicable) Weekly Earnings Date Laid Off (If Applicable) Date Last Work ed Date Return  Dated Ended Reason For Stopping Work Is Employee receiving sick leave Yes Date Began benefits from present employer? No  Is Disability Due  Yes If yes, explain Brief Description of Duties  No To Employment? Date Employee wages ceased. rned to work. Date Employee retu  Yes  Has Employment terminated? No If so, date of termination. Was Employee laid off or was layoff contemplated prior to disability? If so, give day of layoff. Are wages geing continued during disability? Yes  No  If so, does your Employer request reimbursement.  Yes  No Was Employee on the job when disability occurred?  Yes  No No  Has claim been filed for Workmen's Compensation  Yes If yes, WC carrier name and address Yes  No Is Employee member of a union that provides  payment of weekly cash benefits? If yes, give name and address of union.  Is this claimant a N.Y. employee?  No  Full Time  Part Time Yes Normal work week (check boxes to show usual days worked) S M T W TH F S        Gross Earnings 8 weeks prior to disability Week Ending No. Days Day Worked Gross Amount Mo. Yr. 1 2 3 4 5 6 7 8 Contribution % paid by Employee – pre or post tax. Contribution % paid by Employee Employer Name & Address Employer's Telephone Number Fax Number and Email Address Title Authorized Signature Date First Reliance Standard Life Insurance Company, P.O. Box 7749, Philadelphia, PA 19101-7749 EFN-1327

5 WHILE EMPLOYED OR THE CLAIMANT BECOMES SICK OR DISABLED IMPORTANT: USE THIS FORM ONLY WHEN BECOMES SICK OR DISABLED WITHIN FOUR (4) WEEKS AFTER TERMINATION OF EMPLOYMENT. OTHERWISE USE GREEN FORM DB-300. PROVIDER’S STATEMENT (PLEASE AN PART III MEDICAL SWER ALL QUESTIONS AND SIGN) Patients Name Diagnosis and Concurrent Conditions Surgical or Obstetrical Procedure Current Medications  Weekly  Other Frequency of Treatment  Monthly Has patient ever had same If Yes, when Is condition due to injury  Yes or similar symptoms? Yes  No  or sickness arising from  No patient's employment? Date sympto ms first Date patient first Is patient still under consulted you for Yes  your care for this appeared or accident this condition condition?  No happened If condition is due to pregnancy, If patient hospitalized, give name of hospital Admission Date __________________ give LMP and expected date LMP _______________ of delivery. Expected Date Discharge Date __________________ of delivery ___________ From _______________ job?  Yes Date patient was continuously Is patient able to perform his/her  No To _______________ unable to work ally disabled From: To: Patient will be parti Estimate date patient should be able to return to work. MENTAL CONDITION Is the patient competent to endorse Yes  No checks and direct the use of the proceeds thereof?  COMPLETE THIS SECTION ONLY IF DISABILITY IS DUE TO CARDIAC CONDITION CARDIAC  Class 1 (no limitation)  Class 2 (slight limitation) Functional Capacity  Class 3 (marked limitation)  Class 4 (complete limitation) (American Heart Ass'n) Blood Pressure and Dates COMPLETE THIS SECTION ONLY IF DISABILITY IS DUE TO VISUAL IMPAIRMENT VISUAL IMPAIRMENT Snellen Notation What was vision at O.D. O.S. Month Day 20 With Glasses last observation? Without Glasses O.D. O.S. Month Day 20 Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. License Number Licensed in the State of Chiropractor    Psychologist I affirm that Physician I am a  Podiatrist  Nurse-Midwife  Dentist Medical Provider’s Name, Address, ZIP (Please Print or Type) Telephone Number Fax Number Specialty ( ) ( ) Medical Provider's Signature Medical Provider’s Tax ID No. Degree Date IMPORTANT: PLEASE ATTACH ALL MEDICAL RECORDS FROM THREE (3) MONTHS PRIOR TO DATE OF DISABILITY TO PRESENT. ation claims, WCL-13-1(4)(a) and 2 NYCRR 325-1. larly 3 require health care providers to regu HIPAA NOTICE – In order to adjudicate a worker's compens d medical reports are exempt file medical reports of treatments with the Board and the carri er or employer. Pursuant to 45 CFR 164.512 these legally require from HIPAA's restrictions on disclo sure of health information. First Reliance Standard Life Insurance Company, P.O. Box 7749, Philadelphia, PA 19101-7749 EFN-1327

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