Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 1 of 14 GLC-01252 GROUP lOnG-teRm disability claim (Please see FRaUd nOtices attached) EMPLOYER GROUP POLICY NO. ______________________________________________________________________ _____________________________ emPlOyeR - form completion information nOtice OF claim - instructions A. complete the employer’s portion in full and return this portion to address above or fax to the number above include d Copy of enrollment card (if employee contributes to premium) d Copy of approved medical evidence of insurability if required at time of enrollment d If Workers’ Compensation claim filed, include copy of First Report of Accident and the decision B. Give remaining part of form to claimant for completion The Lincoln National Life Insurance Company, PO Box 2609, Omaha, NE 68103-2609 toll free (800) 423-2765 Fax (877) 843-3950 www.LincolnFinancial.com
14
Embed
GROUP lOnG-teRm disability claim (Please see FRaUd …city.milwaukee.gov/ImageLibrary/User/jkamme/EmployeeBenefits/LTD… · GROUP lOnG-teRm disability claim (Please see FRaUd nOtices
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 1 of 14 GLC-01252
GROUP lOnG-teRm disability claim(Please see FRaUd nOtices attached)
c. information needed for withholding and reporting taxes
Doesemployeecontributepost-taxdollarstowardthepremium? Yes NoIfyes,whatpercentispaidbytheemployee?________%if you leave this section blank, we will assume it is 100% employer contribution and calculate Fica taxes accordingly.
nOte: if any portion of this pension benefit is attributable to the employee’s contribution, please provide details including the percentage of his/her contribution to the total contribution. this should include a copy of the contract.
F. information about your rehire or return-to-work policies
a. salaryonly(nocommissions,bonuses,etc.),completequestion1belowb. previousyear’sW-2form,completequestion5below(attachW-2)c. soleproprietor,completequestion8belowd. previousyear’sK-1form,completequestion6below(attachK-1)
e. salaryandcommissions,completequestions1and3belowf. salary,commissionsandbonuses,completequestions1,3and4belowg. salaryanddeferredcompensation,completequestions1and2belowh. salary,deferredcompensationandcommissions,completequestions1,2and3belowi. salary,deferredcompensation,commissionsandbonuses,completequestions1,2,3and4belowj. salaryandK-1earnings,completequestions1and6below
k. W-2withdeferredcompensation,completequestions2and5belowl. partnershipagreement,completequestion7belowm. teacher’scontract,completequestion1belown. anyotherdefinition,completequestion9below
b. information about the physical aspects of the employee’s jobChecktheitemsbelowthatrelatetotheemployee’sjobandcompletetheinformationrequested.Usethesedefinitionsforthefrequencyofoccurrence:
SKIP PAGES 4 & 5 IF YOU ATTACH COPY OF JOB DESCRIPTION.
Page 5 of 14 GLC-01252
can the job be performed by alternating sitting and standing?YesNoDoesthejobrequireusingthefeettooperatefootcontrols?YesNoIfyes,onwhattypeofequipment?Howimportantisgoodvisioninthejob?
c. information about the job as it relates to the disabilityCanthejobbemodifiedtoaccommodatethedisabilityeithertemporarilyorpermanently?YesNoIfyes,explain
d. attachments and signature (Attachacopyoftheemployee’sjobdescription)
Nameofpersoncompletingthisform
X _______________________________________________________ _____________________________________ __________________Signature Title Date
Telephone Fax
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 6 of 14 GLC-01252
GROUP lOnG-teRm disability claim aPPlicatiOn
emPlOyee -formcompletioninformation
aPPlicatiOn FOR GROUP ltd - instructions
A. complete and sign the authorization on the reverse side of this page.Thiswillallowourinsurancecarrierortheirrepresentativetosecureadditionalinformation(ifnecessary)tomakeadecisiononyourrequestforbenefitpayments(donotdetach).
B. complete employee claim statement in full.
attach d AcopyofSocialSecurityandotherincomeentitlementawards(orforwardwhenreceived)
C. Give this authorization and attached claim application to the physician treating you(ifmorethanone,obtainotherformsforcompletionfromemployer).Instructyourattendingphysiciantosendhisstatementalongwithyourstotheinsurancecarrier.
D. WhenthoseformsarereceivedbytheInsuranceCompany,theywilladviseyouofyoureligibilityforbenefitsorofanyadditionalinformationthatmaybeneeded.
DoNotDetach
The Lincoln National Life Insurance Company, PO Box 2609, Omaha, NE 68103-2609toll free (800) 423-2765 Fax (877) 843-3950www.LincolnFinancial.com
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 7 of 14 GLC-01252
Disability
aUtHORiZatiOn FOR Release OF inFORmatiOn
1. i (the undersigned) authorizeanyphysician,medicalprofessional,pharmacistorotherproviderofhealthcareservices,hospital,clinic,othermedicalormedicallyrelatedfacility;insuranceorreinsurancecompany;governmentagency;departmentoflabor;acquaintance;grouppolicyholder;employer;orpolicyorbenefitplanadministratortoreleaseinformationfromtherecordsof:
d dataorrecordsregardingmymedicalhistory, treatment,prescriptions,consultations [includingmedicalandpsychologicalreports,records,charts,notes(excludingpsychotherapynotes),x-rays,filmsorcorrespondence,andanymedicalconditionImaynowhaveorhavehad];
d anyinformationregardinginsurancecoverage;and
d anyinformation,dataorrecordsregardingmyactivities(includingrecordsrelatingtomySocialSecurity,Workers’Compensation,RetirementIncome,financial,earningsandemploymenthistory).
arkansas, louisiana, Rhode island and West Virginia.Anypersonwhoknowinglypresentsafalseorfraudulentclaimforpaymentofalossorbenefitorknowinglypresentsfalseinformationinanapplicationforinsuranceisguiltyofacrimeandmaybesubjecttofinesandconfinementinprison.
colorado. It is unlawful to knowingly provide false, incomplete, or misleading facts or information to aninsurancecompanyforthepurposeofdefraudingorattemptingtodefraudthecompany.Penaltiesmayincludeimprisonment,fines,denialof insuranceandcivildamages.Any insurancecompanyoragentofan insurancecompanywho knowingly provides false, incomplete, ormisleading facts or information to a policyholder orclaimantfor thepurposeofdefraudingorattemptingtodefraudthepolicyholderorclaimantwithregardtoasettlementorawardpayablefrominsuranceproceedsshallbereported to theColoradoDivisionofInsurancewithintheDepartmentofRegulatoryAgencies.
district of columbia.Itisacrimetoprovidefalseormisleadinginformationtoaninsurerforthepurposeofdefraudingtheinsureroranyotherperson.Penaltiesincludeimprisonmentand/orfines.Inaddition,aninsurermaydenyinsurancebenefitsiffalseinformationmateriallyrelatedtoaclaimwasprovidedbytheapplicant.
Kentucky.Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherpersonfilesa statement of claim containing anymaterially false information or conceals, for the purpose ofmisleading,informationconcerninganyfactmaterialtheretocommitsafraudulentinsuranceact,whichisacrime.
new Hampshire.Anypersonwho,withapurposetoinjure,defraudordeceiveanyinsurancecompany,filesastatementofclaimcontaininganyfalse, incompleteormisleadinginformationissubject toprosecutionandpunishmentforinsurancefraud,asprovidedinRSA638:20.
Page 9 of 14 GLC-01252
new Jersey.Anypersonwhoknowinglyfilesastatementofclaimcontaininganyfalseormisleadinginformationissubjecttocriminalandcivilpenalties.
new mexico.Anypersonwhoknowinglypresentsafalseorfraudulentclaimforpaymentofalossorbenefitorknowinglypresentsfalseinformationinanapplicationforinsuranceisguiltyofacrimeandmaybesubjecttocivilfinesandcriminalpenalties.
new york.Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherpersonfilesanapplicationfor insuranceorstatementofclaimcontaininganymateriallyfalse informationorconcealsforthepurposeofmisleading,informationconcerninganyfactmaterialtheretocommitsafraudulentinsuranceact,whichisacrimeandsubjecttoacivilpenaltynottoexceedfivethousanddollarsandthestatedvalueoftheclaimforeachsuchviolation.
Oklahoma.Anypersonwhoknowingly,andwith intent to injure,defraudordeceiveany insurer,makesanyclaimfortheproceedsofaninsurancepolicycontaininganyfalse,incompleteormisleadinginformationisguiltyofafelony.
Puerto Rico.Anypersonwhoknowinglyandwiththeintentionofdefraudingpresentsfalseinformationinaninsuranceapplication,orpresents,helps,orcausesthepresentationofafraudulentclaimforthepaymentofalossoranyotherbenefit,orpresentsmorethanoneclaimforthesamedamageorloss,shallincurafelonyand,uponconviction,shallbesanctionedforeachviolationwiththepenaltyofafineofnotlessthanfivethousanddollars($5,000)andnotmorethantenthousanddollars($10,000),orafixedtermofimprisonmentforthree(3)years,orbothpenalties.Shouldaggravatingcircumstancesarepresent,thepenaltythusestablishedmaybeincreasedtoamaximumoffive(5)years,ifextenuatingcircumstancesarepresent,itmaybereducedtoaminimumoftwo(2)years.
tennessee and Washington.Itisacrimetoknowinglyprovidefalse,incompleteormisleadinginformationtoaninsurancecompanyforthepurposeofdefraudingthecompany.Penaltiesincludeimprisonment,finesanddenialofinsurancebenefits.
FOR all OtHeR states eXclUdinG cOnnecticUt, Kansas, and ViRGinia.Apersonmaybecommittinginsurancefraud,ifheorshesubmitsanapplicationorclaimcontainingafalseordeceptivestatementwithintenttodefraud(orknowingthatheorsheishelpingtodefraud)aninsurancecompany.
F. information about other disability income(Checktheotherincomebenefitsyouarereceivingorareeligibletoreceiveasaresultofyourdisabilityandcompletetheinformationrequested.)
G. information about income tax withholdingIfyourrequestforbenefitsisapproved,shouldTheLincolnNationalLifeInsuranceCompanywithholdincometaxesfromyourbenefitchecks?YesNoIfyes,howmuchshouldbewithheldfromeachcheck.Federaltaxes(minimumis$88.00permonth)$_____________.00H. signature(Requiredforallclaims)
after you have fully completed this form, attach copies of the following materials:– Office notes for the period of treatment for the last two years– test results showing objective findings– Hospital discharge summaries– consulting physician reports
YourName Degree
Specialty Telephone:Fax:
Address
X ______________________________________________________________________________ __________________________________SignatureofAttendingPhysician(nostamp) Date