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PROOF OF LOSS CLAIM STATEMENT
IMPORTANT INFORMATION REGARDING APPLICATION FOR GROUP LONG TERM
DISABILITY AND GROUP LIFE-WAIVER OF PREMIUM BENEFITS
PLEASE READ THESE INSTRUCTIONS BEFORE COMPLETING THE ATTACHED FORMS
must be
This is a multi-purpose form that requires completion in full by all parties concerned. This information
provided two months prior to the end of the elimination period
in order to allow sufficient processing time.
Each responsible party should complete their section as soon as possible. Please fax completed claim forms and
attachments (only) to 267-256-3519 or mail to Reliance Standard Life Insurance Company, P.O. Box 7749,
Philadelphia, PA 19101-7749. If you have any questions, please call our Customer Service Department at 1-
800-351-7500.
THE EMPLOYER IS RESPONSIBLE FOR COMPLETING THE FOLLOWING SECTIONS:
Section 1 Employer's Statement, both sides
Section 2 Occupation Analysis, both sides
THE EMPLOYEE IS RESPONSIBLE FOR COMPLETING THE FOLLOWING SECTIONS:
Section 3 Employee's Statement, both sides
Section 4 Employment and Education Information, both sides
Section 5 Sign and date the Authorization for Use in Obtaining Information
THE ATTENDING PHYSICIAN IS RESPONSIBLE FOR COMPLETING THE FOLLOWING:
Section 6 Physician’s Statement
Please be sure that all responsible parties completing and filing a claim for benefits are aware of the following statements
which concern claim fraud and abuse:
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application is guilty of a crime and may be subject to fines and confinement in prison.
State of California
For your protection, California law requires the following to appear on this form: Any person 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 prison.
State of New Jersey
Any person who knowingly files a statement of claim containing any false or misleading information is subject to
criminal and civil penalties.
State of New York
Any person who knowingly and with intent to defraud any insurance company or other person, files an application
for insurance or statement of claim containing any materially false 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.
State of Oregon
Any person who, with an intent to knowingly defraud any insurance company or other person, files an application for insurance or
statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any
fact material thereto, may be subject to prosecution for insurance fraud.
State of Pennsylvania
Any person who knowingly and with intent to defraud any insurance company or other person, files an application
for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information
concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and
civil penalties.
SECTION 1
EMPLOYER’S STATEMENT
DISABILITY CLAIM
GROUP LONG TERM DISABILITY
GROUP LIFE-WAIVER OF PREMIUM
TO BE COMPLETED BY EMPLOYER
A. INFORMATION ABOUT THE EMPLOYER
B. INFORMATION ABOUT THE EMPLOYEE
IF YES, SEND INITIAL REPORT OF ILLNESS OR INJURY AWARD NOTICE
C. INFORMATION NEEDED FOR WITHHOLDING AND REPORTING TAXES
PERCENTAGES MUST TOTAL 100%. IF LEFT BLANK WE WILL ASSUME 100% OF PREMIUM IS PAID BY EMPLOYER AND THAT EMPLOYEE IS
NOT TAXED ON THIS AMOUNT. FICA TAXES WILL BE CALCULATED ACCORDINGLY
RS-1936-D RELIANCE STANDARD LIFE INSURANCE COMPANY, P.O. BOX 7749, PHILADELPHIA, PA 19101-7749
TO BE COMPLETED BY THE EMPLOYER
DISABILITY CLAIM EMPLOYER'S STATEMENT
D. INFORMATION ABOUT THE CLAIM
E. INFORMATION ABOUT YOUR PENSION PLAN (DO NOT COMPLETE FOR MATERNITY CLAIM)
F. INFORMATION ABOUT YOUR REHIRE OR RETURN-TO-WORK POLICIES
G. REQUIRED ATTACHMENTS AND SIGNATURE
PROOF OF EARNINGS AS DEFINED BY APPLICABLE POLICY (EXAMPLE: PAYROLL RECORDS, W-2, K1, 1099, ETC.).
IF EMPLOYEE WAS COVERED UNDER A PRIOR PLAN, INCLUDE COPY OF PRIOR PLAN.
IF THE EMPLOYEE CONTRIBUTES TO THE PREMIUMS, ATTACH A COPY OF THE ENROLLMENT FORM.
IF YOU HAVE MEDICAL INFORMATION FROM THE EMPLOYEE'S FILE RELATING TO DISABILITY, PLEASE ATTACH COPIES.
IF A WORKERS COMPENSATION CLAIM IS FILED, SEND INITIAL REPORT OF INJURY OR ILLNESS AND AWARD NOTICE.
I CERTIFY THAT THE FACTS AS INDICATED ABOVE ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
X _______________________________________ ___________________________________
RS-1936-D RELIANCE STANDARD LIFE INSURANCE COMPANY, P.O. BOX 7749, PHILADELPHIA, PA 19101-7749
SECTION 2
OCCUPATION ANALYSIS
GROUP LONG TERM DISABILITY
GROUP LIFE-WAIVER OF PREMIUM
TO BE COMPLETED BY THE EMPLOYER
A. GENERAL INFORMATION ABOUT THE EMPLOYEE'S OCCUPATION
OCCASIONALLY
FREQUENTLY
CONTINUOUSLY
OCCASIONALLY FREQUENTLY CONTINUOUSLY
RELATE TO OTHERS
WRITTEN AND VERBAL COMMUNICATIONS
REASONING, MATH AND LANGUAGE
MAKE INDEPENDENT JUDGMENTS
B. INFORMATION ABOUT THE PHYSICAL ASPECTS OF THE EMPLOYEE'S OCCUPATION
OCCASIONALLY
FREQUENTLY
CONTINUOUSLY
ACTIVITY NEVER OCCASIONALLY FREQUENTLY CONTINUOUSLY
RS-1936-D RELIANCE STANDARD LIFE INSURANCE COMPANY, P.O. BOX 7749, PHILADELPHIA, PA 19101-7749
TO BE COMPLETED BY THE EMPLOYER
C. COMPUTER USAGE INFORMATION
D. INFORMATION ABOUT THE OCCUPATION AS IT RELATES TO THE DISABILITY
E. ATTACHMENTS AND SIGNATURE (ATTACH COPY OF THE EMPLOYEE'S OCCUPATION DESCRIPTION
I CERTIFY THAT THE FACTS AS INDICATED ABOVE ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
X _______________________________________ ___________________________________
RS-1936-D RELIANCE STANDARD LIFE INSURANCE COMPANY, P.O. BOX 7749, PHILADELPHIA, PA 19101-7749
SECTION 3
EMPLOYEE'S STATEMENT
DISABILITY CLAIM
GROUP LONG TERM DISABILITY
GROUP LIFE-WAIVER OF PREMIUM
O BE COMPLETED BY THE EMPLOYEE
A. INFORMATION ABOUT YOU
B. INFORMATION ABOUT YOUR FAMILY
(REQUIRED TO DETERMINE YOUR ELIGIBILITY FOR SOCIAL SECURITY BENEFITS)
C. INFORMATION ABOUT THE CONDITION CAUSING YOUR DISABILITY
PLEASE ANSWER THE FOLLOWING QUESTIONS:
FOR AN INJURY, ANSWER THE FOLLOWING QUESTIONS:
D. INFORMATION ABOUT THE DISABILITY
DISABILITY CLAIM EMPLOYEE’S STATEMENT
RS-1936-D RELIANCE STANDARD LIFE INSURANCE COMPANY, P.O. BOX 7749, PHILADELPHIA, PA 19101-7749
TO BE COMPLETED BY THE EMPLOYEE
E. INFORMATION ABOUT PHYSICIANS AND HOSPITALS
LIST ALL MEDICAL PRACTITIONERS CONSULTED FOR THIS CONDITION:
PLEASE ATTACH ADDITIONAL INFORMATION ON SEPARATE SHEET IF MORE DOCTORS WERE CONSULTED
F. INFORMATION ABOUT OTHER DISABILITY INCOME
SOURCE OF INCOME AMOUNT (WK. MONTH) DATE CLAIM DATE DATE
WAS FILED PAYMENTS PAYMENTS
BEGAN ENDED
SALARY CONTINUANCE $___________/_______________________ ______________ ______________
SHORT TERM DISABILITY $___________/_______________________ ______________ ______________
STATE DISABILITY $___________/_______________________ ______________ ______________
WORKERS COMPENSATION $___________/_______________________ ______________ ______________
SOCIAL SECURITY/RETIREMENT $ __________/_______________________ ______________ ______________
_____________ ______________ ______________
SOCIAL SECURITY/DISABILITY $___________/__________
SOCIAL SECURITY FOR DEPENDENTS $___________/__________ _____________ ______________ ______________
CANADIAN PENSION PLAN $___________/_______________________ ______________ ______________
PENSION/RETIREMENT $___________/_______________________ ______________ ______________
PENSION/DISABILITY $___________/_______________________ ______________ ______________
UNEMPLOYMENT $ __________/_______________________ ______________ ______________
NO-FAULT INSURANCE $___________/_______________________ ______________ _______________
JONES ACT $___________/_______________________ ______________ _______________
RAILROAD RETIREMENT $___________/_______________________ ______________ _______________
OTHER (INCLUDE INDIVIDUAL OR GROUP) $___________/__________ _____________ ______________ _______________
G. INFORMATION ABOUT INCOME TAX WITHHOLDING
We are required to withhold federal income tax from any benefit payments upon your request. If benefits are taxable by your
state, we will also withhold state income tax upon your request. We may also send a report to your employer at the end of each
calendar year showing your name, social security number, any benefits paid and any taxes withheld. If you would like us to
withhold any taxes, please indicate the dollar amount to be withheld each week:
H. SIGNATURE (REQUIRED FOR ALL CLAIMS)
Any person who knowingly and with intent to injure, defraud or deceive Reliance Standard Life Insurance Company, files a
statement of claim or submits any information in conjunction with a claim containing fraudulent, false, misleading, incomplete or
deceptive information commits a fraudulent insurance act, which is a crime. These actions will result in the denial of the claim,
and are subject to prosecution under state and/or federal law. Reliance Standard Life Insurance Company will cooperate fully
with any prosecution and will seek any and all appropriate legal remedies.
I CE
RTIFY THAT THE FACTS AS INDICATED ABOVE ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
RS-1936-D RELIANCE STANDARD LIFE INSURANCE COMPANY, P.O. BOX 7749, PHILADELPHIA, PA 19101-7749
SECTION 4
EMPLOYEE'S STATEMENT
TO BE COMPLETED BY THE EMPLOYEE
EMPLOYMENT AND EDUCATION INFORMATION
PLEASE PRINT ALL INFORMATION
PLEASE COMPLETE THE FOLLOWING INFORMATION AS ACCURATELY AS POSSIBLE. THIS DATA IS NEEDED TO HELP MAKE A THOROUGH
EVALUATION OF YOUR CLAIM.
EDUCATION/TRAINING
HIGH SCHOOL:
COLLEGE:
VOCATIONAL TRAINING:
RS-1936-D RELIANCE STANDARD LIFE INSURANCE COMPANY, P.O. BOX 7749, PHILADELPHIA, PA 19101-7749
TO BE COMPLETED BY THE EMPLOYEE
EMPLOYMENT HISTORY
STARTING WITH PRESENT EMPLOYER, PLEASE LIST AND DESCRIBE ALL OCCUPATIONS YOU HAVE HELD IN THE PAST 15 YEARS. IF MORE
THAN 1 OCCUPATION WITH ANY EMPLOYER, PLEASE LIST EACH. ATTACH RESUME OR ADDITIONAL PAPER AS NECESSARY.
RS-1936-D RELIANCE STANDARD LIFE INSURANCE COMPANY, P.O. BOX 7749, PHILADELPHIA, PA 19101-7749
SECTION 5
AUTHORIZATION FOR USE IN OBTAINING INFORMATION
(If the Insured is unable to sign, an authorized person may sign.)
RS-1936-D RELIANCE STANDARD LIFE INSURANCE COMPANY, P.O. BOX 7749, PHILADELPHIA, PA 19101-7749
SECTION 6
PHYSICIAN’S STATEMENT
DISABILITY CLAIM
GROUP LONG TERM DISABILITY
GROUP LIFE-WAIVER OF PREMIUM
This form should be completed by the physician who was treating the claimant when he or she last worked.
TO BE COMPLETED BY THE ATTENDING PHYSICIAN
A. GENERAL INFORMATION
B. PREGNANCY: PHYSICIAN COMPLETES THIS SECTION FOR NORMAL PREGNANCY
C. PHYSICIAN COMPLETES THIS SECTION FOR ALL CONDITIONS EXCEPT NORMAL PREGNANCY
1.
2.
3.(PLEASE PROVIDE COPIES OF TEST RESULTS AND OFFICE NOTES)
4.
5.6.7.
D. PHYSICIAN COMPLETES FOR ANY HOSPITAL CONFINEMENTS
RS-1936-D RELIANCE STANDARD LIFE INSURANCE COMPANY, P.O. BOX 7749, PHILADELPHIA, PA 19101-7749
TO BE COMPLETED BY THE ATTENDING PHYSICIAN
E. DESCRIPTION OF PATIENT’S RESTRICTIONS AND LIMITATIONS
F. PHYSICIAN COMPLETES IF LIMITATIONS ARE MENTAL/NERVOUS IN NATURE
CAPACITY NOT LIMED IT MODERATELYLIMITED EXTREMELY LIMITED
G. PHYSICIAN COMPLETES ONLY IF THE CONDITION IS CARDIAC IN NATURE
H. PHYSICIAN COMPLETES FOR ALL CONDITIONS: PROGNOSIS FOR RECOVERY
IMPORTANT: PLEASE ATTACH ALL MEDICAL RECORDS FROM THREE (3) MONTHS PRIOR TO DATE OF DISABILITY TO PRESENT.
RS-1936-D RELIANCE STANDARD LIFE INSURANCE COMPANY, P.O. BOX 7749, PHILADELPHIA, PA 19101-7749