Fill in a Valid Long Term Disability Template

The Long Term Disability form is a crucial document that helps individuals apply for benefits when they are unable to work due to a disabling condition. This form collects essential information about the employee's medical situation, work history, and other relevant details to determine eligibility for financial support. Completing this form accurately and thoroughly is vital to ensure a smooth claims process, so take a moment to fill it out by clicking the button below.

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The Long Term Disability (LTD) form is a crucial document for employees seeking financial support during extended periods of illness or injury. This form, provided by Mutual of Omaha, serves as the gateway to accessing group long-term disability benefits, offering vital income protection when it's needed most. Completing the form accurately is essential, as the information you provide will determine your eligibility for benefits. The form consists of several sections, each designed to gather specific details about your personal information, your disabling condition, and your work history. Employees must fill out their statements, while employers and physicians also contribute vital information to support the claim. Key elements include personal identifiers, details about the disabling condition, and any other income sources you might have. Additionally, it’s important to indicate whether you want taxes withheld from your benefits, ensuring that you receive the amount you expect. To avoid delays in processing, all sections must be completed thoroughly and clearly, with a special emphasis on legibility and accuracy. Remember to keep a copy of your completed form for your records before submission. This guide will walk you through the process of filling out the LTD form, providing helpful tips and insights along the way.

Long Term Disability Example

A Guide for Successfully Completing the

Group Long-Term Disability Claim Form

Mutual of Omaha appreciates the opportunity to provide you with valuable income protection. We rely on the information you provide on this form to effectively determine if you qualify for group long-term disability benefits.

This guide provides information and instruction to help you successfully complete and submit the claim form. Please consult your employer/benefits administrator if you need assistance in providing information for the form.

IMPORTANT TIPS FOR PAPER COPY SUBMISSION

nPrior to submission, make sure all required information is provided and all questions have been answered completely and accurately. If information is missing or is illegible (unreadable), the processing of your form will be delayed.

nRefer to the guidelines for each section below, which provide valuable information to help you successfully complete the form.

nMake a copy of the completed form for your records before submitting it to Mutual of Omaha/United of Omaha.

GUIDELINES FOR SECTION 1: EMPLOYEE’S STATEMENT

This section is to be completed by the Employee. Please answer all questions in order to avoid possible delays. All dates should indicate the month, date and year.

A. Information About You

nThe Group Policy Number will have eight characters, beginning with “G000” followed by four additional letters or numbers speciﬁc to your employer.

nProvide weight in pounds, and height in feet and inches.

nYour Occupation/Job Title is the title of your position held with the employer.

nIndicate any other Mutual of Omaha/United of Omaha plans in which you are currently insured.

C. Information About Your Disabling Condition

nThe Date First Treated is the date you ﬁrst sought out medical care because of the disabling condition.

D. Information About Work

nThe Last Day Worked is the day before you were ﬁrst absent from work because of the disabling condition.

E. Information About Care and Treatment

nProvide the name, specialty, phone and address for each doctor or hospital that treated you for the disabling condition.

F. Information About Other Income Beneﬁts

nOther Income means money you are currently receiving or have applied to receive from any source in addition to your claim for disability beneﬁts with Mutual of Omaha/ United of Omaha.

nCheck all sources of other income that apply.

G. Information For Tax Withholding

nIf your claim is paid, indicate whether or not you would like Mutual of Omaha to withhold income tax from your beneﬁt payment, and if so, how much. Minimum is $88 per month.

H. Signature

nYour signature is required.

EDUCATION, TRAINING AND WORK EXPERIENCE

nThis form is to be completed by the employee. Please make sure all questions have been answered completely and accurately. If information is missing or is illegible (unreadable), the processing of your form will be delayed.

nVocational rehabilitation services include, but are not limited to (a) job modiﬁcation; (b) job placement;

AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION

This authorization is to be completed by the employee.

nPlease read this section in its entirety. By signing the authorization, you are applying for long-term disability beneﬁts with Mutual of Omaha/United of Omaha, and are agreeing to allow disclosure of personal information to the necessary parties for purposes of claim processing.

nIf the name associated with any of your medical records differs from the name provided on the form, provide any alternate names. This might occur in the event of a name change due to marriage or adoption, for example.

nIMPORTANT: To be complete, the form must be signed by you.

GUIDELINES FOR SECTION 2: EMPLOYER’S STATEMENT

This section is to be completed by the employer. Please answer all questions in order to avoid possible delays. All dates should indicate the month, date and year.

A. Information About the Employer

nThe Group Policy Number will have eight characters, beginning with “G000” followed by four additional letters or numbers.

B. Information About the Employee

nThe Date Employee Became Insured Under This Plan indicates the date in which the employee’s coverage became effective.

nThe Date Employee Became Insured Under Prior Plan indicates the date in which the employee’s coverage was in effect under a plan prior to the Mutual of Omaha plan.

nThe No. of Hours Employee Regularly Works is the number of hours the employee is typically at work per day/per week for the employer.

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LTD Claim Form Guide_1009

C. Information For Tax Withholding

nIf this section is not completed, Mutual of Omaha will assume that premium paid by the employee is with pre-tax dollars.

nIf this is not true, indicate otherwise and provide the percentage amount.

E. Information For Life Waiver

nDate Life Insurance Terminated means the ﬁrst day the coverage is no longer in force.

nIf applicable, the Paid To Date for group life insurance is the date on which the next premium is due.

F. Information About Your Pension Plan

nThis section is not applicable if the disabling condition is maternity.

H. Information About Employee’s Salary

nIndicate the method in which the employee is paid.

nIf hourly, also indicate the hourly rate in which the employee is paid.

nPlease attach supporting payroll documentation.

GUIDELINES FOR SECTION 3: JOB ANALYSIS

This section is to be completed by the employer. Please answer all questions in order to avoid possible delays. All dates should indicate the month, date and year.

A. Information About the Employee’s Job

nOccasionally means the employee does this activity up to 33 percent of the time.

nFrequently means the employee does the activity 34 percent to 66 percent of the time.

nContinuously means the employee does the activity 67 percent to 100 percent of the time.

B. Physical Aspects of the Job

nCheck all the activities that apply to the employee’s job.

nIndicate the frequency with which the employee performs the activity using the guidelines in Section A. Information About the Employee’s Job.

GUIDELINES FOR SECTION 4: SIGNATURE AND ATTACHMENTS

nAttach a copy of the employee’s job description to the claim application.

nAttach any additional documentation that may be helpful when reviewing the application, including further explanation of any question(s) on the application.

nYour signature is required.

GUIDELINES FOR SECTION 5: PHYSICIAN’S STATEMENT

This section is to be completed by the attending physician. Please answer all questions in order to avoid possible delays. All dates should indicate the month, date and year.

REQUIRED FRAUD WARNINGS

Before completing the claim form, please read the Required Fraud Warnings listed on the following page.

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LTD Claim Form Guide_1009

REQUIRED FRAUD WARNINGS (STATE SPECIﬁC WARNINGS APPLY TO THE RESIDENT OF SUCH STATE)

nFraud Warning: 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.

nAlabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject

to restitution fines or confinement in prison, or any combination thereof.

nArkansas/Kentucky/Louisiana/Maine/New Mexico/ Ohio/Tennessee: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or ﬁles a claim containing a false or deceptive statement is guilty of insurance fraud.

nCalifornia: For your protection California law requires

the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to ﬁnes and conﬁnement in state prison.

nColorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, ﬁnes, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

nDistrict of Columbia: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or ﬁnes. In addition, an insurer may deny insurance beneﬁts if false information materially related to a claim was provided by the applicant.

nKansas: 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 as determined by a court of law.

nMaryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

nNew Jersey: Any person who includes any false or misleading information on an application for insurance is subject to criminal and civil penalties.

nNew 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 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.

nOregon: 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 may be a crime and may subject such person to criminal and civil penalties.

nPuerto Rico: Any person who furnishes information verbally or in writing, or offers any testimony on improper or illegal actions which, due to their nature constitute fraudulent acts in the insurance business, knowing that the facts are false shall incur a felony and, upon conviction, shall be punished by a fine of not less than five thousand (5,000) dollars, nor more than ten thousand (10,000) dollars for each violation or by imprisonment for a fixed term of three (3) years, or both penalties. Should aggravating circumstances be present, the fixed penalty thus established may be increased to a maximum of five (5) years; if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.

nRhode Island: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information on an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

nVermont: Any person who knowingly and with intent to defraud any insurance company or other person ﬁles an application for insurance or statement of claims containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto may be committing a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties.

nVirginia: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or ﬁles a claim containing a false or deceptive statement may have violated state law.

Long-Term Disability Claim Form

Mutual of Omaha Insurance Company

United of Omaha Life Insurance Company

Group Insurance Claims Management

Mutual of Omaha Plaza
Omaha, NE 68175-0001
Phone 800-877-5176	Fax 402-997-1865

Section 1 – Employee’s Statement (Answer all questions to avoid delay.)

A. Information About You

Last Name

First Name

Middle Initial

Group Policy Number

Address

City

State/Province

ZIP

Telephone ( )

Email Address

Social Security Number

Date of Birth	Height	Weight	n Male	n Right Handed		n Single	n Widowed
			n Female	n Left Handed		n Married	n Divorced

Name of Your Employer (include Division/Location, if applicable)					Your Occupation/Job Title

Under what other Mutual of Omaha/United of Omaha policies are you currently covered?

Important Notice: If you are age 60 or over, please contact your employer within 31 days of disability to preserve your group life insurance conversion privileges.

If your coverage is written in California, North Carolina or Michigan and includes Survivor Benefits, please check your policy to determine if you can elect a survivor benefit beneficiary. If so, you may obtain a Beneficiary Designation form on the Internet or from your employer.

B. Information About Your Family (Required to determine your eligibility for Social Security benefits.)

Spouse’s Name	Spouse’s Social Security Number	Spouse’s Date of Birth		Is your spouse employed? n Yes
				n No

First and Last Name of any children under the age of 25			Date of Birth
____________________________________________________________________________________			___________________________
____________________________________________________________________________________			___________________________
____________________________________________________________________________________			___________________________

C.Information About Your Disabling Condition

1.If your disability is due to an injury, answer the following questions and then proceed to #3 below.

When did the injury occur?

Where and how did the injury occur?

What is the date you were first treated by a physician?

2. If your disability is due to a pregnancy or an illness, answer the following questions. If not pregnancy-related, proceed to #3 below.

What were your first symptoms?

When did you notice these symptoms?

What is the date you were first treated by a physician?

3. If your disability is due to an injury or an illness, but not pregnancy, answer the following questions.

Why are you unable to work?
Before you stopped working, did your condition require you to change your job or the way you did your job? n Yes						n No If Yes, please explain below.
Is your condition related to your occupation? n Yes	n No If Yes, please explain below.
Have you filed, or do you intend to file a Workers’ Compensation claim? n Yes					n No

D. Information About Work
What is the date of your last day worked before the disability?		On your last day worked, did you work a full day?
		n Yes		n No	If No, please explain.

What is the date you were first unable to work?			Have you returned to work? n Yes, Part-Time			n Yes, Full-Time n No
			What date did you return to work?

If you haven’t yet returned to work, do you expect to?	n Yes, Part-Time			n Yes, Full-Time n No
What date do you expect to be able to return to work?

Are you currently self-employed or working for another employer? n Yes

n No If Yes, provide details.

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Form continued on Page 2


EMPLOYEE: ________________________________________________________________		Page 2 of 10
FAX NUMBER (402) 997-1865	Form must be completed in full at no expense to Mutual of Omaha

E. Information About Care and Treatment (If additional space is needed, please provide details on a separate page.)

Doctor who first provided medical attention to you for your current disability.	Doctor’s Specialty		Telephone (	)
			Fax (	)

Doctor’s Address		Date(s) you were seen by this doctor
		From ____________ To ____________

List all other physicians and/or hospitals you have visited for this condition below.

Doctor’s Name

Doctor’s Address

Doctor’s Name

Doctor’s Address

Name of Hospital

Hospital’s Address

Doctor’s Specialty		Telephone (	)
		Fax (	)

	Date(s) you were seen by this doctor
	From ____________ To ____________
Doctor’s Specialty		Telephone (	)
Doctor’s Specialty		Telephone (	)
		Fax (	)

	Date(s) you were seen by this doctor
	From ____________ To ____________
Department of Treatment		Telephone (	)
Department of Treatment		Telephone (	)
		Fax (	)

	Date(s) you were treated at the hospital
	From ____________ To ____________

Have you ever had the same or a similar condition in the past? n Yes	n No If Yes, provide the following information concerning past treatments.

Doctor’s Name		Doctor’s Specialty		Telephone (	)
				Fax (	)

Doctor’s Address			Date(s) you were seen by this doctor
			From ____________ To ____________

Name of Hospital		Department of Treatment		Telephone (	)
				Fax (	)

Hospital’s Address			Date(s) you were treated at the hospital
			From ____________ To ____________

F. Information About Other Income Benefits (Check all benefits you are receiving or are eligible to receive.)

Source of Income	Amount	Weekly/	Date claim was filed	Date payments began	Date payments ended
		Monthly
Social Security Retirement	___________	____________	_________________	__________________	_________________
Social Security Disability	___________	____________	_________________	__________________	_________________
Canadian Pension Plan	___________	____________	_________________	__________________	_________________
Workers’ Compensation	___________	____________	_________________	__________________	_________________
State Disability	___________	____________	_________________	__________________	_________________
Pension Retirement	___________	____________	_________________	__________________	_________________
Pension Disability	___________	____________	_________________	__________________	_________________
Short-Term Disability	___________	____________	_________________	__________________	_________________
Unemployment	___________	____________	_________________	__________________	_________________
No-Fault Insurance	___________	____________	_________________	__________________	_________________
Other (include Individual or Group benefits) ___________		____________	_________________	__________________	_________________

G. Information For Tax Withholding

If your request for benefits is approved, should Mutual of Omaha/United of Omaha withhold income taxes from your benefit checks? If yes, how much should be withheld from each check (the minimum is $88.00 per month). $____________.00

nYes

nNo

Overpayment Notice: Should you become overpaid at anytime during the duration of this claim we, Mutual of Omaha Insurance Company (Mutual) or United of Omaha Life Insurance Company (United), will request reimbursement of the overpaid amount. This amount is equal to the net benefit you received and any Federal Income Tax paid on your behalf for any time prior to current tax year. Your signature on the claim form authorizes Mutual or United to recover any overpaid Medicare and/or Social Security Tax that was paid on your behalf and certifies you will not attempt to recover a refund or credit of the Medicare and/or Social Security Tax with any Form W-2C that is furnished to you based on recoveries received.

H. Signature (Required for all claims.)

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

The above statements are true and complete to the best of my knowledge and belief.

X ____________________________________________________		_________________________
	Signature of Employee	Date
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EMPLOYEE: ________________________________________________________________					Page 3 of 10
FAX NUMBER (402) 997-1865				Form must be completed in full at no expense to Mutual of Omaha

Education, Training and Work Experience
Name_________________________________________________________________________________________________________________________________
Policy No. ______________________________________________________				Claim No. _______________________________________________

Educational Background
High School Graduate	n Yes	n No	If No, what was the last grade completed? ________________ Last date attended ________________
GED n Yes n No	Field of Study n General n Business n Vocational			n Other
Did you attend college? n Yes		n No	Last Date Attended ________________

Name and Address of College: ___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Major(s): ______________________________________________________________________________________________________________________________

Final Status: n Freshman n Sophomore n Junior n Senior n Undergraduate Degree n Graduate School

Degree(s) earned: ______________________________________________________________________________________________________________________

Other formal training: ___________________________________________________________________________________________________________________

Certification(s):_________________________________________________________________________________________________________________________

Computer Skills: ________________________________________________________________________________________________________________________

Military Service n Yes n No If Yes, in which branch did you serve? __________________________________________________________________________

Rank: _________________________________________________________________________________________________________________________________

Specialty: _____________________________________________________________________________________________________________________________

What computer programs are you able to use?_______________________________________________________________________________________________

List all languages spoken fluently: _________________________________________________________________________________________________________

Work Experience

Please fill out completely. Start with your most recent employment and list chronologically.

Dates: From ___________________ To ___________________

Employer: _____________________________________________________________________________________________________________________________

Job Title: ______________________________________________________________________________________________________________________________

List job duties: _________________________________________________________________________________________________________________________

List physical requirements of job: _________________________________________________________________________________________________________

Product/service produced: _______________________________________________________________________________________________________________

Did you supervise others? n Yes n No

Reason for leaving? _____________________________________________________________________________________________________________________

Dates: From ___________________ To ___________________

Employer: _____________________________________________________________________________________________________________________________

Job Title: ______________________________________________________________________________________________________________________________

List job duties: _________________________________________________________________________________________________________________________

List physical requirements of job: _________________________________________________________________________________________________________

Product/service produced: _______________________________________________________________________________________________________________

Did you supervise others? n Yes n No

Reason for leaving? _____________________________________________________________________________________________________________________

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EMPLOYEE: ________________________________________________________________		Page 4 of 10
FAX NUMBER (402) 997-1865	Form must be completed in full at no expense to Mutual of Omaha

Dates: From ___________________ To ___________________

Employer: _____________________________________________________________________________________________________________________________

Job Title: ______________________________________________________________________________________________________________________________

List job duties: _________________________________________________________________________________________________________________________

List physical requirements of job: _________________________________________________________________________________________________________

Product/service produced: _______________________________________________________________________________________________________________

Did you supervise others? n Yes n No

Reason for leaving? _____________________________________________________________________________________________________________________

Dates: From ___________________ To ___________________

Employer: _____________________________________________________________________________________________________________________________

Job Title: ______________________________________________________________________________________________________________________________

List job duties: _________________________________________________________________________________________________________________________

List physical requirements of job: _________________________________________________________________________________________________________

Product/service produced: _______________________________________________________________________________________________________________

Did you supervise others? n Yes n No

Reason for leaving? _____________________________________________________________________________________________________________________

Dates: From ___________________ To ___________________

Employer: _____________________________________________________________________________________________________________________________

Job Title: ______________________________________________________________________________________________________________________________

List job duties: _________________________________________________________________________________________________________________________

List physical requirements of job: _________________________________________________________________________________________________________

Product/service produced: _______________________________________________________________________________________________________________

Did you supervise others? n Yes n No

Reason for leaving? _____________________________________________________________________________________________________________________

Additional courses taken, hobbies and special skills. Please be specific such as computer skills either personal or professional, sales, carpentry, auto repair, etc.

______________________________________________________________________________________________________________________________________

Are you currently involved in a vocational rehabilitation program? n Yes n No

If yes, please provide the name, address and phone # of the rehabilitation case worker ___________________________________________________________

______________________________________________________________________________________________________________________________________

Are you interested in learning about our vocational rehabilitation program? n Yes n No

What is your employment goal or other work that you would be interested in doing? _______________________________________________________________

Date: ______________________________ Signature: _________________________________________________________________________________________

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AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION

1.I authorize any physician, medical or dental practitioner, hospital, clinic, pharmacy benefit manager, other medical care facility, health maintenance organization, insurer, employer, consumer reporting agency and any other provider of medical or dental services to release records containing the personal information of:

Claimant/Patient Name: __________________________________________________________

(Last)

(First)

(Middle)

2.Personal information includes medical history, mental and physical condition, prescription drug records, alcohol or drug use, financial and occupational information.

3.You may release information to:

Group Disability Management Services

Mutual of Omaha Insurance Company/United of Omaha Life Insurance Company

Mutual of Omaha Plaza

Omaha, NE 68175-0001

Fax 402-997-1865

4.I understand that the personal information that is disclosed will be used by Mutual of Omaha Insurance Company and United of Omaha Life Insurance Company to evaluate my claim for disability benefit plan reimbursement and that if I refuse to sign this authorization my claim for benefits may not be paid.

5.I understand that if the person or entity to whom information is disclosed is not a health care provider or health plan subject to federal privacy regulations, the personal information may be redisclosed without the protection of the federal privacy regulations.

6.This authorization will expire 24 months after the date signed.

7.I understand that I may revoke this authorization at any time by providing a written request to Mutual of Omaha Insurance Company and United of Omaha Life Insurance Company at the address above. If I revoke this authorization, it will not affect any use or disclose of personal information that occurred prior to the receipt of my revocation.

8.I understand that I am entitled to receive a copy of this authorization and that a copy is as valid as the original.

RETAIN A SIGNED COPY FOR YOUR RECORDS

Name(s) used for records (if different than the name below): ________________________________

________________________________________________________________________________

_______________________________________________________________	________________
Signature of Claimant	Date

If Applicable: I am the legal representative of the claimant and I am authorized to grant permission on behalf of the claimant.

Printed Name of Legal Representative:_______________________________________________

Signature of Legal Representative: __________________________________________________

Type of Legal Representative: ______________________________________________________

THIS AUTHORIZATION COMPLIES WITH HIPAA AND OTHER FEDERAL AND STATE LAWS

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EMPLOYEE: ________________________________________________________________		Page 6 of 10
FAX NUMBER (402) 997-1865	Form must be completed in full at no expense to Mutual of Omaha

Section 2 – Employer’s Statement (Answer all questions to avoid delay.)

Employee’s Name

Social Security Number

Date of Birth

Employee’s Address

Employee’s Phone Number

A. Information About the Employer

Company’s Name

Group Policy Number

Class No. or Description

Company’s Address (Number, Street, City, State, ZIP)		Company’s Telephone (		)
		Company’s Fax (		)

Name and Address of Location Where Employee Works	Location No.	Location Telephone (		)
		Location Fax (	)

B. Information About Employee

Employee’s Hire Date	Date Employee became insured under this plan: __________________	No. of hours Employee regularly works per day/per week?

	Date Employee became insured under prior plan: _________________	______ # of hours per/week ______ # of hours per/day

C. Information For Tax Withholding

If this section is left blank, we will calculate FICA taxes based on the following assumption: 100% Employer contribution or any portion paid by Employee is paid with pre-tax dollars.

Does Employee contribute post-tax dollars toward the premium? n Yes n No If Yes, what percent is paid by Employee? ______% Post-Tax

D. Information About the Claim

Before Employee became fully disabled, were changes made to Employee’s job responsibilities due to the disabling condition? n Yes n No

If yes, please describe the changes and when they were made.

Date Employee Last Worked			Did Employee work a full day? n Yes		n No If No, how many hours were worked?

What was Employee’s permanent job on his/her last day worked?				How long had Employee been in this job?

Why did Employee stop working?				Has Employee returned to work? n Yes n No
				If Yes, when?

Is Employee’s condition work related? n Yes	n No		Has a Workers’ Compensation claim been filed? n Yes n No
			If Yes, send initial report of illness/injury and award notice.

Name of Workers’ Comp Carrier		Address of Workers’ Comp Carrier			Contact Person’s Name & Phone No.

Name and Address of Medical Insurance Carrier

Is Employee covered under a Group Life policy with Mutual of Omaha? n Yes n No

E. Information For Life Waiver

Important Notice: If an Employee is age 60 or over, please refer to the policy provisions regarding group life continuation and conversion rights.

Is Employee covered under a Group Life policy with United of Omaha? n Yes	n No If Yes, what is the effective date of the life insurance plan?

What is Employee’s annual salary?	Amount of Life insurance as of last day worked

Master Policy Number

Class

Location

Date Life insurance terminated?

If not terminated, what is the “paid to date”?

Name of beneficiary (per your records)?

Relationship to Employee?

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EMPLOYEE: ________________________________________________________________		Page 7 of 10
FAX NUMBER (402) 997-1865	Form must be completed in full at no expense to Mutual of Omaha

F. Information About Your Pension Plan (Do not complete for maternity.)

Do you have a pension plan? n Yes n No

If Yes, what type?

n Defined Benefit

n Defined Contribution

n401(k)

nProfit Sharing

n Other (specify)

Is Employee eligible for your pension plan? n Yes n No	If eligible, does Employee participate? n Yes n No
	If Yes, when is Employee eligible for benefits under the pension plan?

If Employee is eligible but does not participate, explain why.

G. Information About Your Rehire or Return to Work Policies

Does your company have a rehire or return to work policy for disabled Employees? n Yes n No

Who should we contact if we identify a rehabilitation or return to work option? Name/Title:

Contact No.

H.Information About Employee’s Salary (Please attach supporting payroll documentation.)

(Check all that apply) Employee n is paid hourly ($

hourly rate)

n is salaried

n receives commissions

n receives bonuses

Will Employee file for disability benefits provided by any Employer/Employee Labor Management, State Disability or Union Welfare plan? n Yes n No

If Yes, please answer the following questions. Weekly amount?			Date benefits begin?	Date benefits end?

Is Employee eligible for Salary Continuation?	n Yes	n No If Yes, please answer the following questions.
Weekly amount?		Date benefits begin?		Date benefits end?

Is Employee eligible for Sick Leave? n Yes	n No	If Yes, please answer the following questions.
Weekly amount?		Date benefits begin?		Date benefits end?

Per the definition of Basic Monthly Earnings in your Policy, what are Employee’s pre-disability monthly earnings?

Section 3 – Job Analysis (To be completed by the Employee’s Supervisor or HR Department.

Answer all questions to avoid delay.)

A. Information About Employee’s Job

Job Title

Minimum education or training required?

How long will Employee’s job be held open?

Does Employee perform supervisory functions?

nYes

n No If Yes, how many people are supervised?

Describe Employee’s job duties.

Indicate how each of the following related to Employee’s job.
	Occasionally (0%-33%)	Frequently (34%-66%)	Continuously (67%-100%)
Computer use	____________	____________	____________
Relate to others	____________	____________	____________
Written and verbal communication	____________	____________	____________
Reasoning, math and language	____________	____________	____________
Make independent judgments	____________	____________	____________

Which of the following describe Employee’s working environment? Check all that apply.
n Unprotected heights	n Changes in temperature	n Exposure to dust, fumes and gases
n Being near moving machinery	n Driving automotive equipment	n Other hazards (please explain)

Is Employee required to travel? n Yes n No	If Yes, please answer the following questions.
How does Employee travel? n Automobile	n Plane n Train n Other

What percent of the time does Employee travel?

Where does Employee travel?

MUG1710A_0212

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Click for Long Term Disability File

File Breakdown

Fact Name	Description
Purpose of the Form	The Group Long-Term Disability Claim Form is designed to collect information necessary for determining eligibility for long-term disability benefits provided by Mutual of Omaha.
Completion Requirements	Both the employee and employer must complete their respective sections fully. Incomplete or illegible information may delay the processing of the claim.
Tax Withholding Information	Employees must indicate whether they wish to have income taxes withheld from their benefit payments, with a minimum withholding amount specified.
State-Specific Fraud Warnings	Each state has its own laws regarding fraudulent claims, which must be acknowledged by the claimant. For example, California law requires disclosure that presenting a fraudulent claim is a crime.

Guide to Using Long Term Disability

Completing the Long Term Disability form is an important step in securing the benefits you may need. Once you have filled out the form, it will be reviewed by the insurance company to determine your eligibility. Be sure to follow the steps carefully to avoid any delays in processing your claim.

Begin with Section 1: Employee’s Statement. Fill out your personal information, including your name, address, and Social Security number. Make sure to provide your Group Policy Number, height, and weight.
Answer all questions regarding your disabling condition. Include the date you first sought medical treatment and any relevant details about your condition.
Indicate your last day worked and whether you worked a full day on that date. Provide information about your work status since your disability began.
List all doctors and hospitals that have treated you for your condition, including their contact information and the dates of your visits.
In the Information About Other Income Benefits section, check all sources of income you are receiving or have applied for. Fill in the amounts and relevant dates.
For tax withholding, indicate whether you want income tax withheld from your benefits and specify the amount.
Sign and date the form to confirm that the information you provided is accurate and complete.
Proceed to Section 2: Employer’s Statement. Your employer will need to fill out this section, providing information about your employment and salary.
In Section 3: Job Analysis, your employer will describe your job duties and the physical demands of your role.
Attach any necessary documentation, including your job description, to the claim application.
Finally, ensure that the Physician’s Statement is completed by your attending physician. This section requires their input to support your claim.

After completing these steps, make a copy of the entire form for your records. Submit the form to Mutual of Omaha and keep track of any correspondence related to your claim. This will help ensure that you stay informed about the status of your application.

Get Answers on Long Term Disability

What is the purpose of the Long Term Disability form?

The Long Term Disability form is designed to collect essential information that helps determine your eligibility for group long-term disability benefits. Mutual of Omaha uses this information to assess your claim accurately. It is crucial to complete this form thoroughly to avoid delays in processing.
Who is responsible for completing the Employee’s Statement section?

The Employee’s Statement section must be completed by you, the employee. You are required to answer all questions in this section accurately and completely. Missing or illegible information can significantly delay the processing of your claim.
What should I do if I need assistance while filling out the form?

If you require assistance, it is advisable to consult your employer or benefits administrator. They can provide guidance on how to complete the form and ensure that you provide all necessary information.
What information do I need to provide about my disabling condition?

You must include details such as the date you first sought medical care for your condition, the nature of your disability, and the names and contact information of your treating physicians. This information is vital for assessing the validity of your claim.
How can I ensure my form is processed quickly?

To facilitate prompt processing, follow these tips:
- Answer all questions completely and accurately.
- Make sure your handwriting is legible.
- Provide all required documentation, including your job description and any additional relevant information.
- Make a copy of the completed form for your records before submission.
What happens if I provide false information on the form?

Providing false or misleading information on the Long Term Disability form is considered a fraudulent act. This can result in severe penalties, including criminal charges. It is essential to be honest and accurate when completing your claim.
Is there a specific format I need to follow for dates on the form?

Yes, all dates should be provided in the format of month, day, and year. This consistency helps avoid confusion and ensures that your claim is processed without unnecessary delays.
What should I do if my medical records contain a different name?

If the name on your medical records differs from the name you provided on the form—perhaps due to a name change from marriage or adoption—you should include any alternate names on the form. This information is crucial for accurate processing of your claim.

Common mistakes

Completing the Long Term Disability form can be a complex process. Many individuals make mistakes that can delay their claims. One common error is failing to provide complete information in the Employee’s Statement section. Each question must be answered thoroughly. Missing or incomplete responses can lead to processing delays.

Another frequent mistake involves illegible handwriting. If the information is difficult to read, it may cause misunderstandings or require additional follow-up. It is advisable to print clearly or type responses when possible.

Individuals often overlook the importance of accurate dates. Dates should reflect the month, day, and year format. Incorrect dates can lead to confusion regarding the timeline of the disability and may affect eligibility.

Many applicants neglect to include their Group Policy Number, which is crucial for identifying the specific insurance plan. This number must be accurate and complete to avoid delays in processing the claim.

Some individuals fail to report other income sources accurately. It is essential to disclose any additional income received from other benefits. This includes Social Security or Workers’ Compensation, as this information impacts the determination of benefits.

Another common oversight is not providing full medical history. The form requires details about all physicians and treatments related to the disabling condition. Incomplete medical records can lead to questions and further delays.

Applicants sometimes forget to sign the form. A missing signature can halt the entire process. It is vital to ensure that all required signatures are present before submission.

Some individuals do not make a copy of the completed form for their records. Keeping a copy can be beneficial for future reference and to track the status of the claim.

Failing to check for additional documentation that may support the claim is another mistake. Including relevant documents, such as job descriptions or medical records, can strengthen the application and expedite the review process.

Lastly, individuals may not consult their employer or benefits administrator for assistance. Seeking help can clarify any confusing sections and ensure that all necessary information is provided accurately.

Documents used along the form

When applying for long-term disability benefits, you may need to submit several other forms and documents alongside the Long Term Disability form. Each of these documents serves a specific purpose in ensuring that your claim is processed accurately and efficiently. Below is a list of commonly required forms and documents.

Employer’s Statement: This document is filled out by your employer. It provides essential information about your employment status, including your job title, hours worked, and the effective date of your insurance coverage. This statement helps the insurance company verify your employment details and eligibility for benefits.
Physician’s Statement: Completed by your attending physician, this form outlines your medical condition and the extent of your disability. It includes details about your diagnosis, treatment history, and how your condition affects your ability to work. This information is crucial for the insurance company to assess your claim.
Authorization to Disclose Personal Information: This authorization allows your healthcare providers to share your medical records with the insurance company. By signing this document, you consent to the release of necessary information to facilitate your claim processing.
Job Description: A copy of your job description may be required to provide context about your work responsibilities and the physical demands of your position. This document helps the insurance company understand how your disability impacts your ability to perform your job duties.
Education, Training, and Work Experience Form: This form provides information about your educational background and work history. It helps the insurance company evaluate your qualifications and any potential for vocational rehabilitation services, should you need them.

Gathering these documents and ensuring they are completed accurately is vital for a smooth claims process. Taking the time to prepare each form carefully can help avoid delays in receiving your benefits. If you have questions or need assistance, don't hesitate to reach out to your employer or benefits administrator for guidance.

Similar forms

Short-Term Disability Claim Form: Like the Long Term Disability form, this document is used to apply for benefits when an employee is unable to work due to a medical condition. Both forms require detailed information about the employee's condition and work history.
Workers’ Compensation Claim Form: This form is similar as it also seeks benefits for employees who are injured or become ill due to their job. It requires information about the injury, medical treatment, and work history.
Social Security Disability Application: This application is used to apply for federal benefits for individuals unable to work due to a disability. Both forms require medical documentation and personal information to establish eligibility.
Health Insurance Claim Form: Used to file claims for medical expenses, this form shares similarities in that it requires details about medical treatments and providers. Both forms aim to secure financial support for health-related issues.
Life Insurance Claim Form: This document is similar in that it requires information about the insured individual and their condition. Both forms are used to access benefits related to a person’s health and financial needs.
Unemployment Benefits Application: This form is utilized by individuals who have lost their job through no fault of their own. Like the Long Term Disability form, it requires personal and employment information to determine eligibility.
Pension Benefits Application: This application is for individuals seeking to access retirement funds. Similar to the Long Term Disability form, it requires detailed employment history and personal information.
Family Medical Leave Act (FMLA) Request Form: This form is used to request leave for medical reasons. It requires information about the employee’s medical condition, much like the Long Term Disability form.
Medical Release Form: This document allows medical providers to share health information with insurance companies. It parallels the Long Term Disability form in that it involves the disclosure of medical information to support a claim.

Dos and Don'ts

When filling out the Long Term Disability form, it is important to follow specific guidelines to ensure a smooth application process. Below is a list of five things you should do and five things you should avoid.

Do: Answer all questions completely and accurately to prevent delays.
Do: Make a copy of the completed form for your records before submission.
Do: Provide clear and legible information, especially regarding medical treatment and conditions.
Do: Include all necessary documentation, such as job descriptions and medical records.
Do: Consult with your employer or benefits administrator if you need help with the form.

Don't: Leave any questions unanswered, as this can lead to processing delays.
Don't: Submit the form without reviewing it for accuracy and completeness.
Don't: Provide false or misleading information, as this can result in penalties.
Don't: Forget to sign the form, as an unsigned application will not be processed.
Don't: Submit the form without checking the specific requirements for your state, as fraud warnings vary by location.

Misconceptions

Understanding the Long Term Disability (LTD) claim form is crucial for those seeking benefits. Unfortunately, several misconceptions can lead to confusion and potential delays in the application process. Here are nine common misconceptions, along with clarifications to help navigate this important form.

All sections of the form can be skipped if they don’t apply. Many believe that if a section doesn’t seem relevant, it can be left blank. However, every section should be addressed, even if it means indicating "not applicable" to ensure clarity.
The form can be submitted without a copy for personal records. Some individuals think they can submit the form without keeping a copy. In reality, retaining a copy is essential for your records and any future inquiries.
Only medical professionals need to fill out the form. While the physician's statement is crucial, the employee must also complete their sections accurately. Both perspectives are necessary for a comprehensive review.
Providing incomplete information is acceptable as long as it’s accurate. Incomplete information can lead to delays. All questions should be answered thoroughly to avoid processing issues.
Once submitted, the process is automatic. Many expect that submitting the form guarantees approval. However, the review process involves careful consideration, and additional information may be requested.
Tax withholding is optional and can be ignored. This is not true. If you wish for taxes to be withheld from your benefits, you must indicate this on the form. Otherwise, the default will be applied.
Only recent medical conditions need to be disclosed. Some applicants think only current conditions matter. However, any previous similar conditions may also be relevant and should be disclosed.
There’s no need to consult an employer or benefits administrator. Many assume they can complete the form independently. In fact, consulting with your employer can provide valuable insights and assistance in filling out the form correctly.
Submitting the form electronically is the same as submitting a paper copy. Some believe that the submission method doesn’t matter. However, specific guidelines apply to each method, and following the correct protocol is vital for timely processing.

By addressing these misconceptions, individuals can better prepare for the Long Term Disability claim process, ensuring that their applications are complete and accurate. This preparation can lead to a smoother experience and a quicker resolution of claims.

Key takeaways

When filling out the Long Term Disability form, several key points should be considered to ensure a smooth submission process. The following takeaways provide essential guidance:

Complete All Sections: Ensure that every section of the form is filled out completely. Missing or illegible information can cause delays in processing your claim.
Accurate Information: Provide accurate details regarding your medical condition, employment history, and any other income benefits. Double-check for accuracy before submission.
Documentation: Attach necessary documentation such as your job description and any other relevant medical records. This additional information can support your claim.
Employer's Statement: The employer must complete their section accurately. They should provide information about your employment status and salary, as this is crucial for the claim's assessment.
Tax Withholding: Indicate whether you want taxes withheld from your benefit payments. Specify the amount if applicable, as this will affect your net benefits.
Keep Copies: Make copies of the completed form and any attachments for your records. This can be helpful for future reference or in case of any disputes.

These points serve as a guide to help individuals navigate the Long Term Disability claim process effectively.

Fill in a Valid Long Term Disability Template

Long Term Disability Example

File Breakdown

Guide to Using Long Term Disability

Get Answers on Long Term Disability

What is the purpose of the Long Term Disability form?

Who is responsible for completing the Employee’s Statement section?

What should I do if I need assistance while filling out the form?

What information do I need to provide about my disabling condition?

How can I ensure my form is processed quickly?

What happens if I provide false information on the form?

Is there a specific format I need to follow for dates on the form?

What should I do if my medical records contain a different name?

Common mistakes

Documents used along the form

Similar forms

Dos and Don'ts

Misconceptions

Key takeaways