Common use of Required Forms and Information Clause in Contracts

Required Forms and Information. The attached flowchart should be followed when absent under the Wage Loss Replacement / Short Term Disability Benefits. Benefits will be paid only if the employee supplies the company with the following: • The company’s “Initial Claim for Short Term Disability Benefits – Physician’s Statement” form that is completed by their doctor. In order to qualify for benefits, the employee must be physically seen by a physician at least sometime during the contractual waiting period. If the employee has not been seen by a physician during the contractual waiting period, his/her benefits will not commence until he/she has been seen by a physician. The employee will return the “Initial Claim for Short Term Disability Benefits – Physician’s Statement” form as soon as possible. It is understood that benefits may be delayed until the form has been submitted to the Company. If the employee is having trouble getting an appointment to see their doctor, please notify the company nurse to make the Company aware of this situation. Ongoing medical information supporting the employee’s total disability will be required by the Company. Benefits may be suspended if the requested information is not provided within a reasonable period of time. This suspension of benefits will not apply if the requested information is not provided through no fault of the employee. The Company may also require the employee to be examined by a Company appointed physician, and/or other medical professional. The Company will assume the costs of all medical documentation supplied by the employee to the Company.