Fill in a Valid Boston Mutual Claim Bd 1321 0706 Template

The Boston Mutual Claim Bd 1321 0706 form is a crucial document used for filing a claim for group disability benefits through Boston Mutual Life Insurance Company. Completing all sections of this form accurately and promptly after a disability begins can help ensure timely processing of your claim. If assistance is needed while filling out the form, you can contact their toll-free number.

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Fill in a Valid Boston Mutual Claim Bd 1321 0706 Template

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The Boston Mutual Claim Bd 1321 0706 form is an essential document for individuals seeking benefits under the Boston Mutual Life Insurance Company's group disability insurance. Completing this form promptly after a disability begins is crucial to avoid delays in processing requests for benefits. This form contains several components that must be filled out by the employee, the treating physician, and the employer. The employee must provide personal information, details about their medical condition, and the circumstances surrounding the disability, including any prior similar conditions. The treating physician is tasked with confirming the patient's diagnosis and the treatment plan, while the employer must verify the employee's work status and contributions to disability premiums. All completed forms must be submitted to a designated address or fax number provided by the insurance company. It is important to follow the outlined instructions carefully to ensure a smooth claims process and avoid complications related to missing or incorrect information.

Boston Mutual Claim Bd 1321 0706 Example

Boston Mutual Life Insurance Company

Group Disability

Claim Filing Instructions

IMPORTANT: All portions of this claim form must be completed after disability begins to avoid undue delay in processing claimant’s request for benefits. If you have any questions when completing this form, please call our:

Toll Free Number - (800) 320-4445

1.Complete "Employee - Initial Disability Benefits Claim Form" in full.

2.Have treating physician complete the "Physician - Initial Disability Claim Form" and return to you.

3.Have Employer complete the "Employer - Initial Claim Form" and return to you.

4.Submit all completed forms to the address below or you may fax all completed forms to our:

Toll Free Fax Number - (888) 594-5729.

Mail To:

Boston Mutual Life Insurance Company

Benefits Administration

P.O. Box 268956

Oklahoma City, OK 73126-8956

BD-1321-0706

Mail to: Boston Mutual Life Insurance Company

Benefits Administration

P.O. Box 268956

Oklahoma City, OK 73126-8956

Toll Free Phone # 1-800-320-4445

Toll Free Fax # 1-888-594-5729

EMPLOYER – INITIAL CLAIM FORM

Employee Name:

Occupation:

Social Security Number:

Hire Date:

STATUS OF EMPLOYMENT: Full Time: ❏

Part Time: ❏

Days per week: ________ Hours per day: _________

If employee’s status has changed, please check the appropriate box and provide change date below:

Lay Off: ❏

Leave of Absence: ❏

Terminated: ❏

Retired: ❏

PREMIUMS:

Are the employee’s disability premium contributions deducted pre-tax ❏ or post-tax ❏?

What percentage of the disability premiums do you pay?_________%

Are Social Security taxes withheld from employee’s pay check? Yes ❏ No ❏

Date that last disability premiums deducted from payroll:___________ Amount deducted: $__________

SALARY AT TIME OF DISABILITY:

Hourly: $_________

Weekly: $__________ Monthly: $__________

Annually: $__________________

$_____________________

W-2, previous calendar year

Year-to-date, current calendar year

Date last worked?______________________

Has employee returned to work? Yes ❏ No ❏ Return date: ________________ Full Time ❏ Part Time ❏

Is the employee receiving or eligible to receive any of the following?

Dates Benefits

Yes

Amount

Company Name and Phone Number

Begin

End

Other Group

Disability

❏

Salary

Continuation

❏

Sick Leave

❏

PTO/PPT

❏

Other (Bonus, etc.)

❏

Retirement/Pension

❏

Is disability the result of work related injury/illness? Yes ❏ No ❏

If yes, has a Workers' Compensation claim been filed? Yes ❏ No ❏

Please provide name and phone number of Workers' Compensation carrier:

Employer Name:

Office Phone Number:

Fax Phone Number:

Street Address:

City:

State:

Zip Code:

Form completed by: (please print)

Title:

Signature:

Date:

This documents that the above statements are true and complete to the best of my knowledge.

BD-1321-0706

Mail to: Boston Mutual Life Insurance Company

Benefits Administration

P.O. Box 268956

Oklahoma City, OK 73126-8956

Toll Free Phone # 1-800-320-4445

Toll Free Fax # 1-888-594-5729

EMPLOYEE - INITIAL DISABILITY CLAIM FORM

WARNING: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim containing any false, incomplete, or misleading information may be guilty of insurance fraud and subject to criminal and civil penalties.

Name:

Social Security Number:

Date of Birth:

Complete Mailing Address:

Complete Resident Address:

Telephone Number:

Do you have dependents under age 18? Yes ❏ No ❏ If yes, please list dependent names and birth dates below:

1)Please list medical condition or injury causing disability:

2)If disability is the result of an accident, please explain where, when, and how accident happened:

3)Is your disability the result of your employment? Yes ❏ No ❏ If yes, please submit copy of Workers' Compensation award or denial letter.

4)Please list all dates of medical treatment pertaining to current disability:

5)Have you ever had or been treated for same or

similar condition? Yes ❏ No ❏ If yes, please explain:

6)Please list name and phone number of treating physician(s):

7)Date Last Worked:

Date Returned to Work:

8)If you have not returned to work, what is the anticipated return date?

❏Full Time: ______________________

❏Part Time:______________________

9)If your request for benefits is approved, do you want Federal Taxes withheld from each benefit check? Yes ❏ No ❏

If yes, please indicate dollar amount below:

(Minimum amount required is $87 per month.) $_______________

10) Please identify other income sources and amounts of income which you are receiving or may be entitled to receive during this disability:

Social Security - Disability ❏ Retirement ❏	Yes ❏	No ❏	$__________	V.A. Benefits	Yes ❏	No ❏	$___________
Dependent Social Security	Yes ❏	No ❏	$__________	Sick Leave or Wage Continuation	Yes ❏	No ❏	$___________
State Disability	Yes ❏	No ❏	$__________	Retirement (normal, early, or disability)	Yes ❏	No ❏	$___________
Other Group Disability Coverage	Yes ❏	No ❏	$__________

Include a copy of your award or denial letter from any source that you have received.

AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION

I hereby authorize the entities specified below to disclose any information about my entire medical record and history of treatment for physical and/or emotional illness

to include psychological testing, except psychotherapy notes, to individuals representing Boston Mutual Life Insurance Company (BMLIC) who are involved in determining whether I am eligible for benefits under my insurance coverage. Those so authorized are: a) licensed physicians or medical practitioners; b) hospitals, clinics or medically-related facilities; c) health plans; d) Veteran’s Administration; e) past or present employers; f) pharmacy; g) insurance companies; h) Social Security Administration; i) retirement systems; j) Department of Motor Vehicles, and k) Workers’ Compensation carrier.

NOTICE: Information authorized for release may include information on communicable or venereal diseases such as hepatitis, syphilis, gonorrhea, Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) or other conditions for which you may have been treated. This authorization excludes disclosure of the result of a test for HIV if you have tested HIV positive but have not developed symptoms of the disease AIDS. Such test results shall not be discovered or published. Nothing in the caveat will prohibit this authorization from including the fact that you have AIDS.

I understand that I may refuse to sign this authorization; however, if I do not sign the authorization, my failure to sign the authorization may result in a denial of benefits. I understand that I may revoke this authorization at any time by writing to Boston Mutual Life Insurance Company, Benefits Administration, P.O. Box 268956, Oklahoma City, Oklahoma 73126-8956 or calling toll free 1-800-320-4445. I understand that my right to revoke this authorization is limited to the extent that BMLIC has taken action in reliance on the authorization; or, the law provides BMLIC with the right to contest my insurance coverage or a claim under my insurance coverage. A copy of this authorization will be as valid as the original. I understand that if protected health information is disclosed to a person or organization that is not required to comply with federal privacy regulations, the information may be re-disclosed and no longer protected by federal privacy regulations.

For health insurance coverage, this authorization will expire twenty-four months from the date it is signed or upon termination of my insurance policy, whichever occurs first. For insurance coverage other than health insurance, this authorization will expire twenty-four months from the date it is signed or upon expiration of my claim for benefits, whichever occurs first. For Arizona residents, release of HIV/AIDS released information can only be disclosed for a period not to exceed 180 days from the date shown below.

Signature :____________________________________________ Print Insured’s/Patient Name: ______________________________________ Date:_______________

Please retain a copy for your personal records, or you may request a copy from our company.

BD-1321-0706

FAILURE TO SIGN & DATE FORM WILL DELAY BENEFITS

Mail to: Boston Mutual Life Insurance Company

Benefits Administration

P.O. Box 268956

Oklahoma City, OK 73126-8956

Toll Free Phone # 1-800-320-4445

Toll Free Fax # 1-888-594-5729

PHYSICIAN - INITIAL DISABILITY CLAIM FORM

Patient’s Name:

Social Security Number:

Date of Birth:

Diagnosis: Please list diagnosis resulting in patient’s temporary total disability (including complications)
Diagnosis: ________________________________________________________________				ICD9 Code: __________________________________
Diagnosis: ________________________________________________________________				ICD9 Code: __________________________________

Is disability the direct result of patient’s employment?		Yes ❏ No ❏

Is disability the result of a pregnancy? Yes	❏ No ❏	If yes, date pregnancy was diagnosed:

Delivery date: (if delivered)		Expected delivery date: (if not delivered)
History: Was the patient referred to you?	Yes ❏ No ❏ Unknown ❏ If yes, please provide name and phone number of referring physician:

Date symptoms first appeared or accident happened?			Date patient first consulted you for this condition?

Are you aware if this patient has ever had the same or similar condition? Yes ❏ No ❏ If yes, please provide explanation including first date of onset.

Treatment: Is patient still under your care? Yes ❏ No ❏ If yes, date of next appointment: _____________________________________________

List all treatment dates:______________________________________________________________________________________________________

Please describe treatment plan: _______________________________________________________________________________________________

If patient is no longer under your care, please provide name and phone number of current physician:		Unknown ❏

Has patient been confined to a hospital? Yes ❏ No	❏ Admitted: ___________________________	Discharged: _____________________________
Hospital Name:	Phone Number:

If surgery is/was necessary, please list procedure(s):

Date scheduled:	Date performed:

Prognosis: Please list date(s) of temporary total disability (unable to work) From: ________________ Through: __________________

If patient is currently totally disabled, please indicate the anticipated length of disability by checking the appropriate box below:

Months: ❏

❏

❏ or Permanently Disabled ❏ or Other

❏ ________________________

Impairment: List functional limitations/restrictions that render your patient temporarily totally disabled:

Attending Physician’s Name: (please print)

Degree:

Specialty:

Street Address:

City:

State/Zip Code:

Office Phone Number:

Fax Phone Number:

Federal Tax ID Number:

Form completed by:

Title:

Signature of Physician:	Date:

Attention Physician: This form documents your verification that the above named individual is totally disabled from their occupation. You will be asked periodically for updates related to the individual’s disability and treatment plan.

BD-1321-0706

Click for Boston Mutual Claim Bd 1321 0706 File

File Breakdown

Fact Name	Detail
Form Title	Boston Mutual Life Insurance Company Group Disability Claim Filing Instructions
Completion Requirement	This form must be completed after the disability begins to ensure timely processing.
Primary Contact	For questions, call Boston Mutual at 1-800-320-4445.
Submission Method	Completed forms can be mailed or faxed. The toll-free fax number is 1-888-594-5729.
Mailing Address	Boston Mutual Life Insurance Company, Benefits Administration, P.O. Box 268956, Oklahoma City, OK 73126-8956.
Fraud Warning	False information can lead to criminal and civil penalties for fraud.
Employer's Role	The employer must complete the 'Employer - Initial Claim Form' and return it to the employee.
Patient's Required Authorization	The patient must authorize the disclosure of their medical information for claim processing.
State-Specific Notice	Arizona residents have restrictions on HIV/AIDS information disclosure, limited to 180 days.

Guide to Using Boston Mutual Claim Bd 1321 0706

Completing the Boston Mutual Claim Bd 1321 0706 form is an essential step in the claim process for disability benefits. It is crucial to follow each step carefully and provide accurate information to ensure that the claim is processed without delays. The next steps involve gathering necessary details from different parties, including your employer and physician.

Fill out the "Employee - Initial Disability Benefits Claim Form." Provide all requested information in full.
Contact your treating physician and ask them to complete the "Physician - Initial Disability Claim Form." Make sure they return it to you.
Request your employer to complete the "Employer - Initial Claim Form." They should also return this form to you.
Compile all the completed forms and submit them to the provided address or fax them to the toll-free number.

Mail all forms to:

Boston Mutual Life Insurance Company
Benefits Administration
P.O. Box 268956
Oklahoma City, OK 73126-8956

If you prefer to fax the documents, use the number: 1-888-594-5729.

For any questions during this process, do not hesitate to call the toll-free number: 1-800-320-4445.

Get Answers on Boston Mutual Claim Bd 1321 0706

What is the Boston Mutual Claim Bd 1321 0706 form used for?

The Boston Mutual Claim Bd 1321 0706 form is a crucial document for filing a group disability claim with Boston Mutual Life Insurance Company. It serves as a request for benefits following a disability, guiding employees, their treating physicians, and employers through the necessary steps to ensure a thorough and prompt claim process.

What steps do I need to follow to complete the form?

To successfully complete the form, adhere to these steps:

Fill out the "Employee - Initial Disability Benefits Claim Form" in full.
Have your treating physician complete the "Physician - Initial Disability Claim Form" and return it to you.
Have your employer fill out the "Employer - Initial Claim Form" and return it to you.
Submit all completed forms via mail or fax. The mailing address is Boston Mutual Life Insurance Company, Benefits Administration, P.O. Box 268956, Oklahoma City, OK 73126-8956. You can fax the forms to the toll-free fax number at (888) 594-5729.

How can I ensure my claim is processed quickly?

To avoid delays in processing your claim, complete all sections of the form fully and accurately after your disability has begun. Make sure that both your physician and employer provide their input without unnecessary delays. Missing signatures or incomplete information can significantly slow down the process, so double-check each form before submission.

What information is required from my employer on this form?

Your employer must provide various details such as:

Your full name, social security number, and occupation.
Your employment status (full-time or part-time) and its change history.
Information about any disability premium contributions, including deductions and percentages paid.
Your salary at the time of disability, including hourly, weekly, and annual figures.
Confirmation of whether you have returned to work and any other benefits you might be receiving.

Ensuring that your employer fills this out accurately will aid in a smoother claims process.

What happens if I fail to complete the authorization for protected health information?

If you do not sign the authorization to disclose your protected health information, there may be consequences. Without your authorization, your claim for benefits could be denied. The authorization is necessary for Boston Mutual Life Insurance Company to verify your disability and establish eligibility for the claimed benefits. Always remember to include this crucial step when submitting your form.

Common mistakes

When filling out the Boston Mutual Claim Bd 1321 0706 form, many individuals make mistakes that can delay the processing of their claims. One common error is failing to complete all sections of the form. It is crucial to provide every detail requested, including personal information, employment status, and medical history. Incomplete forms can result in significant delays, as the insurance company may need to contact you for the missing information.

Another mistake often made is the lack of accurate dates. Whether it’s the date of the last worked day, the beginning of disability, or any medical treatment dates, accurate timing is essential. Misstating these dates can hinder the claim processing and possibly affect the outcome. Ensure that every date is correct and clearly noted.

A third common error is not having the required forms filled out by the necessary parties. Each claim requires the input of the employee, employer, and treating physician. Neglecting to follow through and collect signatures from these individuals can lead to a backlog or denial at the initial review stage.

People also frequently overlook the importance of including supporting documents. For instance, if the disability stems from a work-related injury, omitting the Workers’ Compensation claim details can create confusion. Provide all relevant documentation with your submission to support your claim.

Lastly, individuals often forget to sign and date their forms before submission. This simple oversight can cause immediate delays as the insurance company typically cannot process unsigned forms. To avoid these issues, double-check that all signatures and dates are completed before sending in your claim.

Documents used along the form

The Boston Mutual Claim Bd 1321 0706 form is an essential document for filing a disability claim with the Boston Mutual Life Insurance Company. However, there are several other forms and documents that often accompany it to ensure a smooth claims process. Below is a brief overview of these related documents, each playing a significant role in supporting your claim.

Employee - Initial Disability Benefits Claim Form: This form is filled out by the employee to provide personal details, including medical conditions and any other relevant factors contributing to the disability claim.
Physician - Initial Disability Claim Form: Filled out by the employee's treating physician, this form confirms the disability and provides medical details necessary for the claim evaluation.
Employer - Initial Claim Form: An essential document completed by the employer, it verifies the employee's work status and any contributions made towards disability premiums.
Authorization to Use or Disclose Protected Health Information: This authorization permits the sharing of medical records with Boston Mutual Life Insurance Company, which can expedite the claims process.
Social Security Administration Forms: If applicable, these forms document the employee's application or eligibility for Social Security Disability benefits, serving as critical support for the claim.
Workers' Compensation Claim Documents: If the disability results from a work-related injury, any associated Workers' Compensation documents must be included to establish eligibility for both claims.
Medical Records: Complete medical records detailing assessments, treatments, and physician notes related to the claim help provide a clearer picture of the employee's condition.
Personal Identification Documents: Copies of identification such as Social Security cards and driver's licenses may be required to verify the identity of the claimant.
Income Verification Documents: These may include pay stubs, W-2 forms, or tax returns to establish the employee's income level prior to the disability.

By preparing these documents along with the Boston Mutual Claim Bd 1321 0706 form, claimants can enhance the chances of a smooth and timely claims process. Each form serves a specific purpose and collectively helps paint a comprehensive picture of the situation. Always ensure all forms are completed accurately and submitted in a timely manner to avoid delays in receiving benefits.

Similar forms

The Boston Mutual Claim Bd 1321 0706 form is essential for initiating a disability claim with Boston Mutual Life Insurance Company. This form requires detailed information from both the employee and their employer. Several other documents serve similar purposes in disability claims and insurance contexts. Below is a comparison of the Boston Mutual Claim form with eight other documents relevant to disability claims and insurance procedures:

Employee’s Claim for Disability Benefits Form: Like the Boston Mutual form, this document collects the employee’s information and details about their disability. It also requires verification from medical professionals to support the claim.
Employer's Statement of Disability Benefits: Similar to the Employer section of the Boston Mutual form, this document confirms the employee’s employment status and salary, providing necessary context and information for the claim process.
Physician's Report on Disability: Mirroring the Physician section of the Boston Mutual form, this document describes the medical condition causing the employee’s disability and includes the physician’s evaluation and prognosis.
Social Security Disability Application: This application serves a similar purpose of documenting disability. It requires detailed health information and should be filed when the employee is seeking federal benefits, much like the Boston Mutual form for insurance benefits.
Workers’ Compensation Claim Form: This form is relevant when the disability is work-related. Like the Boston Mutual form, it entails information about the injury, medical treatment, and relevant employment history.
Short-Term Disability Claim Form: Used for policies other than those provided by Boston Mutual, this document similarly collects information to evaluate the individual’s eligibility for short-term benefits.
Long-Term Disability Claim Form: While focusing on long-term benefits, this document shares many structural similarities with the Boston Mutual form, aiming to assess the claimant’s ongoing eligibility for extended disability coverage.
Healthcare Authorization Form: This form authorizes medical providers to share information pertaining to the claimant’s health, paralleling the confidentiality aspects highlighted in the authorization section of the Boston Mutual form.

Each of these documents plays a crucial role in the claims process, requiring precise information to ensure a thorough and timely review of benefits eligibility.

Dos and Don'ts

When filling out the Boston Mutual Claim BD 1321 0706 form, it is crucial to ensure a smooth process. Here are key actions you should take, along with some things to avoid:

Do: Complete the "Employee - Initial Disability Benefits Claim Form" entirely.
Do: Have your treating physician fill out the "Physician - Initial Disability Claim Form" and return it to you.
Do: Obtain your employer’s completion of the "Employer - Initial Claim Form" and have them return it to you.
Do: Mail or fax all completed forms to Boston Mutual Life Insurance Company using the provided address or fax number.

Don't: Forget to verify that all sections of the form are filled out after your disability begins.
Don't: Submit incomplete forms, as this can lead to delays in processing your claim.
Don't: Provide any incorrect or misleading information; this may lead to penalties.
Don't: Fail to sign and date the form, as missing signatures can also delay your benefits.

By following these guidelines, you can help ensure that your claim is processed efficiently and accurately.

Misconceptions

Misconception 1: The form can be completed before the disability begins.

This is not accurate. All sections of the Boston Mutual Claim Bd 1321 0706 form must be filled out after the claimant's disability has commenced. Filing it prematurely can lead to delays in processing the claim.

Misconception 2: Only one party needs to submit the claim form.

In truth, multiple parties must complete their respective sections. The employee, treating physician, and employer all have specific forms to complete and submit in order for the claim to proceed effectively.

Misconception 3: Faxing the form is not an option.

This is incorrect. The Boston Mutual form can be submitted via fax. Claimants can use the toll-free fax number provided to ensure timely processing of their claims.

Misconception 4: Any medical provider can sign off on the claim.

The treating physician is specifically required to complete the necessary section. This ensures that the medical information provided is accurate and credible.

Misconception 5: Employees must have a full-time status to qualify for benefits.

This is misleading. Both part-time and full-time employees can file for disability benefits, as the claim form accommodates different employment statuses.

Misconception 6: Only work-related injuries are eligible for claims.

This is not entirely true. While work-related injuries do have specific reporting requirements, claims can be made for various types of disabilities that aren’t necessarily connected to the workplace.

Misconception 7: The completion of the form is optional.

This is false. Completing the form is a critical step in the claims process. Failing to fill it out properly—or at all—will result in delays or outright denial of benefits.

Misconception 8: The form serves only to document medical conditions.

While documenting medical conditions is essential, the form also addresses the claimant's employment status, salary, and any other income sources. These factors collectively influence the eligibility for benefits.

Misconception 9: Signature and date on the form are inconsequential.

This is a significant misunderstanding. An unsigned form can lead to delays, as it indicates that the information has not been verified by the claimant. Signing and dating the form is essential for processing.

Key takeaways

When filling out and using the Boston Mutual Claim BD 1321 0706 form, there are several key points to keep in mind to ensure a smooth process.

Timeliness is crucial. All sections of the claim form should be completed after the disability begins. This will help avoid delays in processing the request for benefits.
Complete all necessary forms. It is important to fill out the "Employee - Initial Disability Benefits Claim Form" fully. Additionally, the treating physician must complete the "Physician - Initial Disability Claim Form," and the employer should also fill out the "Employer - Initial Claim Form." All forms must be collected together.
Submission method. Completed forms can be submitted via mail or fax. If mailing, send the documents to the designated address, which is Boston Mutual Life Insurance Company Benefits Administration, P.O. Box 268956, Oklahoma City, OK 73126-8956. Alternatively, you can fax all the completed forms to the toll-free fax number provided.
Provide accurate information. Each form should be filled out accurately, especially details concerning employment status, salary, and any additional income that may affect the claim. Inaccuracies can lead to delays or denials of benefits.
Follow the instructions carefully. Pay attention to all warnings and instructions on the form. For example, understanding the implications of signing the authorization for the release of protected health information is vital.

Awareness of these key takeaways can significantly facilitate the claims process. It is recommended to keep copies of all submitted documents for personal records.