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SECTION 1 EMPLOYER’S STATEMENT

DISABILITY CLAIM GROUP LONG TERM DISABILITY GROUP LIFE-WAIVER OF PREMIUM

TO BE COMPLETED BY EMPLOYER

THIS CLAIM IS FOR (EMPLOYEE NAME) SOCIAL SECURITY NUMBER DATE OF BIRTH
A. INFORMATION ABOUT THE EMPLOYER
1. COMPANY'S NAME Central Washington Public Utilities UIP		PROVIDE APPLICABLE POLICY NUMBER(S): Group Policy Number 134069 Long Term Disability Life-Waiver of Premium 166103 & 166100
2. ADDRESS (STREET, CITY, STATE, ZIP)
3. NAME AND ADDRESS OF DIVISION WHERE EMPLOYEE WORKS (IF DIFFERENT FROM ABOVE)
B. INFORMATION ABOUT THE EMPLOYEE
1. DATE EMPLOYEE WAS HIRED? (MTH, DAY, YR)	3. DATE EMPLOYEE BECAME INSURED LTD LIFE
	UNDER THIS PLAN?
	MTH DAY YR MTH DAY YR
2. WHAT WAS THE EMPLOYEE'S REGULARLY SCHEDULED WORK WEEK? hrs/wk.	UNDER YOUR PRIOR PLAN?
		MTH DAY YR MTH DAY YR
LTD LIFE			LIFE BENEFIT IN
4. PLEASE IDENTIFY THE CLASS OF THIS EMPLOYEE: (Refer to Policy Schedule of Benefits)Class 1 - Full-Time Emp Class 1 - Full-Time			FORCE
5. DATE TO WHICH PREMIUM IS PAID FOR THIS EMPLOYEE
MTH DAY YR MTH DAY YR			$
6. THE EMPLOYEE IS (CHECK ALL THAT APPLY). PROVIDE COPY OF PAYROLL RECORD AS OF LAST DAY WORKED HOURLY (RATE: ) UNION EXEMPT FULL-TIME COMMISSIONED SALARIED NON-UNION NON-EXEMPT PART-TIME RECEIVES BONUSES
7. IF SALARIED, BASIC MONTHLY EARNINGS AS OF LAST DAY WORKED		8. EFFECTIVE DATE OF CURRENT SALARY OR HOURLY RATE / / MTH DAY YR
9. WILL EMPLOYEE FILE FOR DISABILITY BENEFITS PROVIDED BY ANY EMPLOYER/EMPLOYEE LABOR MANAGEMENT, STATE DISABILITY OR UNION WELFARE PLAN? YES NO A. IF YES, WHAT IS THE WEEKLY AMOUNT? B. WHAT TYPE OF BENEFIT? C. WHEN DO BENEFITS BEGIN? END?
10. IS CONDITION WORK RELATED? YES NO		11. HAS CLAIM BEEN FILED WITH WORKERS COMPENSATION? YES NO IF YES, SEND INITIAL REPORT OF ILLNESS OR INJURY AWARD NOTICE
12. NAME AND ADDRESS OF YOUR WORKERS COMPENSATION CARRIER: (Include Policy Number) Contact Name: Phone Number:
13. NAME AND ADDRESS OF YOUR MEDICAL INSURANCE CARRIER OR ADMINISTRATOR IF SELF FUNDED: (Include Policy Number) Contact Name: Premera Blue Cross, 0000 000xx Xx. XX, Xxxxxxxxx Xxxxxxx, XX 00000 Phone Number: 000.000.0000 Policy No. Xxxxxx - 1023545
C. INFORMATION NEEDED FOR WITHHOLDING AND REPORTING TAXES
PERCENTAGE OF PREMIUM PAID BY EMPLOYER: _0 % IS EMPLOYEE TAXED ON THIS AMOUNT? YES NO PERCENTAGE OF PREMIUM PAID BY EMPLOYEE: 100 % PRE-TAX DOLLARS POST-TAX DOLLARS 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

TO BE COMPLETED BY THE EMPLOYER

DISABILITY CLAIM EMPLOYER'S STATEMENT

D. INFORMATION ABOUT THE CLAIM

1. WERE THERE ANY CHANGES TO THE EMPLOYEE'S OCCUPATIONAL RESPONSIBILITIES DUE TO THE DISABLING CONDITION BEFORE THE EMPLOYEE BECAME FULLY DISABLED? YES NO IF YES, WHAT WERE THE CHANGES AND WHEN WERE THEY MADE? (please attach)

2. WHAT WAS THE EMPLOYEE'S PERMANENT OCCUPATION ON HIS OR HER LAST DAY AT WORK?

3. HOW LONG HAS THE EMPLOYEE BEEN IN THIS OCCUPATION?

4. LAST DAY EMPLOYEE ACTUALLY WORKED (MONTH,DAY, YR.) / /

5. ON THAT DAY, DID THE EMPLOYEE WORK A FULL DAY? YES NO IF NO, HOW MANY HOURS WERE WORKED?

6. WHY DID EMPLOYEE STOP WORKING?

LAYOFF TERMINATION FOR CAUSE FAMILY MEDICAL LEAVE ACT RESIGNATION RETIRED DISABILITY

E. INFORMATION ABOUT YOUR PENSION PLAN (DO NOT COMPLETE FOR MATERNITY CLAIM)

1. DO YOU HAVE A PENSION PLAN? YES NO

2. IF YES, WHAT TYPE?

DEFINED BENEFIT 401K DEFINED CONTRIBUTION PROFIT SHARING OTHER (EXPLAIN) 401(a), 457

3. IS THE EMPLOYEE ELIGIBLE FOR YOUR PENSION PLAN? YES NO

4. IF ELIGIBLE, DOES THE EMPLOYEE CONTRIBUTE? YES NO

5. IF YES, WHAT PERCENTAGE?

6. IF THE EMPLOYEE IS PARTICIPATING, WHEN IS HE OR SHE ELIGIBLE FOR BENEFITS UNDER THE PLAN? (Month,Day,Year)

7 IS THE EMPLOYEE RECEIVING ANY OTHER INCOME RELATED TO THIS DISABILITY? YES NO SOURCE AMOUNT PER WEEK/MONTH?

F. INFORMATION ABOUT YOUR REHIRE OR RETURN-TO-WORK POLICIES

1. DOES YOUR COMPANY HAVE A REHIRE OR RETURN-TO-WORK POLICY FOR DISABLED EMPLOYEES? YES NO

2. DO YOU HAVE FULL OR PART-TIME POSITIONS AVAILABLE THAT THIS EMPLOYEE WOULD BE SUITED FOR UNDER A SUPERVISED REHABILITATION PROGRAM? YES NO

3. WHAT IS THE NAME, TITLE AND TELEPHONE NUMBER OF THE INDIVIDUAL WE SHOULD CONTACT IF WE IDENTIFY A REHABILITATION OR RETURN-TO-WORK OPTION?

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.

NAME/TITLE OF PERSON COMPLETING THIS FORM

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 CERTIFY THAT THE FACTS AS INDICATED ABOVE ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

SIGNATURE DATE

( )

TITLE TELEPHONE EXT.

( )

E-MAIL ADDRESS FAX

TO BE COMPLETED BY THE EMPLOYER

SECTION 2 OCCUPATION ANALYSIS GROUP LONG TERM DISABILITY

GROUP LIFE-WAIVER OF PREMIUM

THIS CLAIM IS FOR (EMPLOYEE'S NAME)	SOCIAL SECURITY NUMBER				DATE OF DISABILITY (MONTH, DAY, YEAR)
A. GENERAL INFORMATION ABOUT THE EMPLOYEE'S OCCUPATION
OCCUPATION TITLE	DOT CODE (DICTIONARY OF OCCUPATIONAL TITLES)				MINIMUM EDUCATION OR TRAINING REQUIRED
DOES THE EMPLOYEE PERFORM SUPERVISORY FUNCTIONS? NO YES IF YES, HOW MANY PEOPLE ARE SUPERVISED? Describe Major Tasks 1. Describe Major Tasks 2. Describe Major Tasks 3.
CHECK THE ITEMS BELOW THAT RELATE TO THE EMPLOYEE'S OCCUPATION, USE THESE DEFINITIONS FOR THE FREQUENCY OF OCCURRENCE. OCCASIONALLY MEANS THE PERSON DOES THE ACTIVIITY 1% TO 33% OF THE TIME FREQUENTLY MEANS THE PERSON DOES THE ACTIVITY 34% TO 66% OF THE TIME CONTINUOUSLY MEANS THE PERSON DOES THE ACTIVITY 67% TO 100% OF THE TIME OCCASIONALLY FREQUENTLY CONTINUOUSLY RELATE TO OTHERS WRITTEN AND VERBAL COMMUNICATIONS REASONING, MATH AND LANGUAGE MAKE INDEPENDENT JUDGMENTS
WHICH OF THE FOLLOWING DESCRIBE THE EMPLOYEE'S WORKING ENVIRONMENT? CHECK ALL THAT APPLY. UNPROTECTED HEIGHTS CHANGES IN TEMPERATURE OR HUMIDITY EXPOSURE TO DUST, FUMES, AND GASES BEING NEAR MOVING MACHINERY DRIVING AUTOMOTIVE EQUIPMENT OTHER HAZARDS
IS THE EMPLOYEE REQUIRED TO TRAVEL?		NO		YES (IF YES, COMPLETE THE FOLLOWING INFORMATION)
HOW DOES THE EMPLOYEE TRAVEL? (AUTOMOBILE, PLANE, ETC.)			WHERE DOES THE EMPLOYEE TRAVEL?		WHAT PERCENT OF THE TIME DOES THE EMPLOYEE TRAVEL?
B. INFORMATION ABOUT THE PHYSICAL ASPECTS OF THE EMPLOYEE'S OCCUPATION
CHECK THE ITEMS BELOW THAT RELATE TO THE EMPLOYEE'S OCCUPATION AND COMPLETE THE INFORMATION REQUESTED. USE THESE DEFINITIONS FOR THE FREQUENCY OF OCCURRENCE: OCCASIONALLY MEANS THE PERSON DOES THE ACTIVIITY 1% TO 33% OF THE TIME FREQUENTLY MEANS THE PERSON DOES THE ACTIVITY 34% TO 66% OF THE TIME CONTINUOUSLY MEANS THE PERSON DOES THE ACTIVITY 67% TO 100% OF THE TIME ACTIVITY NEVER OCCASIONALLY FREQUENTLY CONTINUOUSLY STANDING WALKING SITTING BALANCING STOOPING KNEELING CROUCHING CRAWLING REACHING/WORKING OVERHEAD CLIMBING STAIRS Number of Stairs: LADDER Height of Ladder Describe Activity PUSHING. LBS. PULLING. LBS. LIFTING/CARRYING. LBS.
CAN THE OCCUPATION BE PERFORMED BY ALTERNATING SITTING AND STANDING?						YES	NO

DOES THE OCCUPATION REQUIRE USING FEET TO OPERATE FOOT CONTROLS?						YES	NO IF YES, ON WHAT TYPE OF EQUIPMENT:

IS GOOD VISUAL ACUITY REQUIRED IN THE OCCUPATION? YES NO
WHAT ARE THE MAJOR TASKS REQUIRING USE OF ONE OR BOTH HANDS ONE HAND BOTH HANDS

TO BE COMPLETED BY THE EMPLOYER

C. COMPUTER USAGE INFORMATION

IS USE OF A COMPUTER REQUIRED? NO YES (IF YES, CHECK ALL USES THAT APPLY): WORD PROCESSING SPREADSHEETS DATA-ENTRY E-MAIL OTHER (SPECIFY):

PERCENTAGE OF TIME SPENT WORKING ON COMPUTER %

HAS ANY NECESSARY COMPUTER TRAINING BEEN PROVIDED? YES NO

D. INFORMATION ABOUT THE OCCUPATION AS IT RELATES TO THE DISABILIT<

WOULD MODIFIED OR ALTERNATE EMPLOYMENT BE CONSIDERED TO ACCOMMODATE ANY WORK RELATED RESTRICTIONS (WHERE APPLICABLE AND APPROPRIATE)?

YES NO IF YES, EXPLAIN

E. ATTACHMENTS AND SIGNATURE (ATTACH COPY OF THE EMPLOYEE'S OCCUPATION DESCRIPTION

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 CERTIFY THAT THE FACTS AS INDICATED ABOVE ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

SIGNATURE DATE

( )

TITLE TELEPHONE EXT.

( )

E-MAIL ADDRESS FAX

SECTION 3 EMPLOYEE'S STATEMENT

DISABILITY CLAIM GROUP LONG TERM DISABILITY GROUP LIFE-WAIVER OF PREMIUM

TO BE COMPLETED BY THE EMPLOYEE

A. INFORMATION ABOUT YOU
1. LAST NAME FIRST MIDDLE INITIAL
2. ADDRESS CITY STATE/PROVINCE ZIP
3. TELEPHONE: AREA CODE ( )		4. SOCIAL SECURITY NUMBER
5. DATE OF BIRTH (MONTH, DAY, YR)	6. HEIGHT WEIGHT	7. MALE FEMALE	8. XXXXXXX SINGLE WIDOWED STATUS MARRIED DIVORCED
9. YOUR EMPLOYER (INCLUDE DIVISION IF APPLICABLE)
10. OCCUPATION		11. DOMINANT HAND RIGHT LEFT
B. INFORMATION ABOUT YOUR FAMILY (REQUIRED TO DETERMINE YOUR ELIGIBILITY FOR SOCIAL SECURITY BENEFITS)
1. SPOUSE'S NAME (LAST, FIRST)
2. DATE OF BIRTH (MONTH, DAY, YR)		3. IS YOUR SPOUSE EMPLOYED YES NO
4. DO YOU HAVE ANY CHILDREN UNDER AGE 18? YES NO 5. DO YOU HAVE HANDICAPPED CHILDREN (REGARDLESS OF AGE)? YES NO 6. DO YOU HAVE ANY CHILDREN AGE 18-19, WHO ARE FULL TIME STUDENTS IN ELEMENTARY OR SECONDARY SCHOOLS? YES NO IF YOU ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, PLEASE LIST NAMES. (LAST, FIRST) DATE OF BIRTH
C. INFORMATION ABOUT THE CONDITION CAUSING YOUR DISABILITY
PLEASE ANSWER THE FOLLOWING QUESTIONS:
1. WHAT WERE YOUR FIRST SYMPTOMS?
2. WHEN DID YOU NOTICE THEM?		3. DATE YOU WERE FIRST TREATED BY A PHYSICIAN? (MONTH, DAY, YR)
4. WHY ARE YOU UNABLE TO WORK?
5. BEFORE YOU STOPPED WORKING, DID YOUR CONDITION REQUIRE YOU TO CHANGE YOUR OCCUPATION OR THE WAY YOU DID YOUR OCCUPATION? YES NO
6. HAVE YOU FILED, OR DO YOU INTEND TO FILE A WORKERS COMPENSATION CLAIM? YES NO
FOR AN INJURY, ANSWER THE FOLLOWING QUESTIONS:
7. WHERE AND HOW DID THE INJURY OCCUR?
8. DATE THE INJURY OCCURRED (MONTH, DAY, YR)		9. DATE YOU WERE FIRST TREATED FOR THIS INJURY BY A PHYSICIAN (MONTH, DAY, YR)
D. INFORMATION ABOUT THE DISABILITY
1. DATE YOU WERE FIRST UNABLE TO WORK ON A FULL TIME BASIS (MONTH, DAY, YR)
2. LAST DAY YOU WORKED BEFORE THE DISABILITY (MONTH, DAY, YR)
3. DID YOU WORK A FULL DAY? YES NO IF NO, EXPLAIN.
4. HAVE YOU RETURNED TO WORK? YES NO PART TIME (DATE) FULL TIME (DATE)
5. IF YOU HAVE NOT RETURNED TO WORK, DO YOU EXPECT TO? YES NO PART TIME DATE FULL TIME DATE

DISABILITY CLAIM EMPLOYEE’S STATEMENT

TO BE COMPLETED BY THE EMPLOYEE

E. INFORMATION ABOUT PHYSICIANS AND HOSPITALS
DATE YOU WERE FIRST TREATED FOR THE CURRENT ILLNESS OR INJURY: LIST ALL MEDICAL PRACTITIONERS CONSULTED FOR THIS CONDITION:
DOCTOR'S NAME	TELEPHONE ( ) FAX ( )	SPECIALTY:
ADDRESS (STREET, CITY, STATE, ZIP)	DATES SEEN
DOCTOR'S NAME	TELEPHONE ( ) FAX ( )	SPECIALTY:
ADDRESS (STREET, CITY,	DATES SEEN
PLEASE ATTACH ADDITIONAL INFORMATION ON SEPARATE SHEET IF MORE DOCTORS WERE CONSULTED
HOSPITAL
ADDRESS (STREET, CITY, STATE, ZIP)		DATES OF CONFINEMENT FROM TO
F. INFORMATION ABOUT OTHER DISABILITY INCOME
CHECK THE OTHER INCOME BENEFITS YOU ARE RECEIVING OR ARE ELIGIBLE TO RECEIVE AS A RESULT OF YOUR DISABILITY AND COMPLETE THE INFORMATION REQUESTED
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	$ /
XXXXX 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: Federal Tax to be Withheld ($88.00 Minimum per month, whole dollars only) State Tax to be Withheld ($10.00 Minimum per month, whole dollars only)
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 CERTIFY THAT THE FACTS AS INDICATED ABOVE ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. SIGNATURE DATE E-MAIL ADDRESS

H. INFORMATION ABOUT ELECTRONIC DEPOSIT

I authorize RSL to send my disability payments to the Bank designated below for electronic deposit in my Account. I understand that I may terminate this arrangement at any time by writing to the RSL address above.

🞏 Yes Set-up Direct Deposit Bank/Financial Institution Information

Name of Bank (Print)

Address of Bank

City, State Zip

Choose Type of Account

🞏 Checking 🞏 Savings

Bank Transit/Routing Number (9 Digits)

Personal Account Number

Or Attach a Voided Check imprinted with your name.

I. SIGNATURE (REQUIRED FOR ALL CLAIMS)

I CERTIFY THAT THE FACTS AS INDICATED ABOVE ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

SIGNATURE DATE E-MAIL ADDRESS

SECTION 4 EMPLOYEE'S STATEMENT

TO BE COMPLETED BY THE EMPLOYEE

EMPLOYMENT AND EDUCATION INFORMATION
PLEASE PRINT ALL INFORMATION
1. CLAIMANT'S NAME:
2. POLICY NUMBER: 134069
3. SOCIAL SECURITY NUMBER:
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:
1. COURSE OF STUDY:
2. HIGHEST GRADE COMPLETED:
3. DID YOU OBTAIN YOUR GED IF YOU DID NOT GRADUATE FROM HIGH SCHOOL? YES NO IF YES, WHEN? IF NO, DO YOU PLAN TO OBTAIN YOUR GED IN THE FUTURE?: YES NO
COLLEGE:
1. DID YOU ATTEND COLLEGE? YES NO
2. WHERE?
3. COURSE OF STUDY:
4. DEGREE? YES NO	5. NUMBER OF YEARS COMPLETED:
6. TYPE OF DEGREE: WHEN?
VOCATIONAL TRAINING:
1. WHERE?
2. WHAT TYPE?
3. CERTIFICATE OR LICENSE OBTAINED?
4.WHAT SPECIALIZED TRAINING HAVE YOU HAD INCLUDING EQUIPMENT/MACHINERY USED?
5. DO YOU HAVE KNOWLEDGE OR PROFICIENCY WITH PERSONAL COMPUTERS? YES NO 6. IF YES, PLEASE LIST SOFTWARE PROGRAMS YOU HAVE USED:

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.
1. NAME OF EMPLOYER:
2. START DATE:	3. END DATE:	4. OCCUPATION TITLE:	5. MONTHLY SALARY:
6. REASON FOR LEAVING:
7. DETAIL YOUR DUTIES:
8. WHAT WERE THE PHYSICAL/MENTAL REQUIREMENTS?
9. DID YOU USE A COMPUTER? NO YES (IF YES, CHECK ALL USES THAT APPLY): WORD PROCESSING SPREADSHEETS DATA-ENTRY E-MAIL OTHER (SPECIFY):
10. NAME OF EMPLOYER:
11. START DATE:	12. END DATE:	13. OCCUPATION TITLE:	14. MONTHLY SALARY:
15. REASON FOR LEAVING:
16. DETAIL YOUR DUTIES:
17. WHAT WERE THE PHYSICAL/MENTAL REQUIREMENTS?
18. DID YOU USE A COMPUTER? NO YES (IF YES, CHECK ALL USES THAT APPLY): WORD PROCESSING SPREADSHEETS DATA-ENTRY E-MAIL OTHER (SPECIFY):
19. NAME OF EMPLOYER:
20. START DATE:	21. END DATE:	22. OCCUPATION TITLE:	23. MONTHLY SALARY:
24. REASON FOR LEAVING:
25. DETAIL YOUR DUTIES:
26. WHAT WERE THE PHYSICAL/MENTAL REQUIREMENTS?
27. DID YOU USE A COMPUTER? NO YES (IF YES, CHECK ALL USES THAT APPLY): WORD PROCESSING SPREADSHEETS DATA-ENTRY E-MAIL OTHER (SPECIFY):
28. PROJECTED RETURN TO WORK DATE?		29. HAVE YOU CONTACTED YOUR FORMER EMPLOYER? YES NO
30. HAVE YOU BEEN LOOKING FOR EMPLOYMENT? YES NO
31. ARE YOU FAMILIAR WITH YOUR LTD POLICY’S RETURN TO WORK INCENTIVES AND REHABILITATION SERVICES? YES NO
32. DO YOU USE A COMPUTER AT HOME? YES NO		33. DO YOU HAVE INTERNET ACCESS? YES NO

PO Box 8330

Philadelphia, PA 00000-0000

Phone (000) 000-0000

Fax (000) 000-0000

AUTHORIZATION FOR USE IN OBTAINING INFORMATION

NAME OF INSURED: INSURED'S DATE OF BIRTH:

POLICYHOLDER:

Central Washington Public Utilities U

To all physicians and other health care professionals, hospitals, other health care institutions, insurers, medical, hospital and prepaid health plans, pharmacies, pharmacy benefit managers, employers, group policyholders, contract holders, governmental agencies (including but not limited to the Internal Revenue Service and the Social Security Administration), private and/or public benefit plan administrators, and/or attorney representatives, including but not limited to covered entities and business associates under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the accompanying regulations:

You are authorized to provide Reliance Standard Life Insurance Company and/or its authorized administrators, including but not limited to Matrix Absence Management, with my complete medical records including, including but not limited to all information concerning medical care, advice, and/or treatment provided to me, the above named Insured, and/or any employment, salary, tax and/or benefit-related information concerning me, the above named Insured. This medical or health information may include information on the diagnosis and treatment of mental illness, alcohol, and drug use. This also may include information on the diagnosis, treatment, and testing results related to HIV, AIDS, and sexually transmitted diseases, unless otherwise restricted by state law. I also understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and will no longer be subject to protection under HIPAA and the accompanying regulations. A statement of Reliance Standard Life Insurance Company’s privacy policy is available at xxx.xxxx.xxx or upon request.

Reliance Standard Life Insurance Company will not condition the provision of treatment, payment, enrollment in a health plan, or eligibility for benefits on the provision of this Authorization, except that this Authorization may be required to allow a covered entity to disclose protected health information where such disclosure is necessary to evaluate my claim for benefits.

I understand that any such information will be used for the purpose of evaluating my claim for benefits. Upon request, I understand that I am entitled to receive a copy of this Authorization. This Authorization is valid from the date signed for the duration of the claim, and may be revoked by me at any time upon written request to the address above. A reproduction of this Authorization shall be considered as valid as the original.

Date: Insured's Signature:

(If the Insured is unable to sign, an authorized person may sign.)

Date: Authorized Person's Signature: Description of Authorized Person’s authority to sign on behalf of Insured:

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

SECTION 6 PHYSICIAN’S STATEMENT DISABILITY CLAIM

GROUP LONG TERM DISABILITY GROUP LIFE-WAIVER OF PREMIUM

A. GENERAL INFORMATION
This claim is for (Patient’s Name)				Policy Number 134069
Date of Birth (Month, Day, Year)	Height (Ft., Inches)	Weight (Lbs.)	Blood Pressure	Patient’s Social Security Number
Primary Diagnosis including ICD9 or ICD-10 code
B. PREGNANCY: PHYSICIAN COMPLETES THIS SECTION FOR NORMAL PREGNANCY
1. DATE OF LAST MENSTRUAL PERIOD		2. EXPECTED DATE OF DELIVERY		3. TYPE OF DELIVERY EXPECTED	4 DATE OF DELIVERY
5. INITIAL VISIT FOR THIS PREGNANCY		6. LAST DATE OF TREATMENT		7. EXPECTED LENGTH OF POSTPARTUM RECOVERY
C. PHYSICIAN COMPLETES THIS SECTION FOR ALL CONDITIONS EXCEPT NORMAL PREGNANCY
1. PRIMARY DIAGNOSIS (INCLUDING ICD-9 or ICD-10 CODE):
2. SYMPTOMS (subjective)
3. OBJECTIVE FINDINGS: (PLEASE PROVIDE COPIES OF TEST RESULTS AND OFFICE NOTES)
4. ARE THERE ANY SECONDARY CONDITIONS CONTRIBUTING TO DISABILITY? IF YES, WHAT ARE THEY? (INCLUDING ICD-9 OR or ICD-10 DSMIII R CODE):
5. WHEN DID SYMPTOMS FIRST APPEAR / / MTH DAY YR		6. DATE OF PATIENT’S FIRST VISIT / / MTH DAY YR		7. DATE OF PATIENT’S LAST VISIT / / MTH DAY YR	8. FREQUENCY OF VISITS
9. WAS THE PATIENT REFERRED BY ANOTHER MEDICAL PRACTITIONER?				10. IF SO, XXXXXXX THE NAME AND ADDRESS.
11. IS THE PATIENT’S CONDITION WORK RELATED? 🞏YES 🞏 NO IF YES, EXPLAIN:
12. HAS THE PATIENT UNDERGONE A SURGICAL PROCEDURE? 🞏 YES 🞏 NO IF NO, SKIP TO 13.
12a. PROCEDURE:		12b. DATE:		12c. FACILITY (NAME/ADDRESS)
13. DO YOU EXPECT SURGERY IN THE NEAR FUTURE? 🞏YES 🞏 NO IF NO, SKIP TO 14.
13a. PROCEDURE:		13b. DATE:		13c. FACILITY (NAME/ADDRESS)
14. WHAT PRESCRIBED MEDICATION IS THE PATIENT CURRENTLY TAKING AND WHAT DOSAGE?
15. HAVE YOU REFERRED THE PATIENT FOR OTHER TYPES OF CONSULTATIONS? 🞏 YES 🞏 NO IF YES, EXPLAIN.
16. HAVE YOU REFERRED THE PATIENT TO A MEDICAL REHABILITATION OR THERAPY PROGRAM? IF YES, PLEASE IDENTIFY:
D. PHYSICIAN COMPLETES FOR ANY HOSPITAL CONFINEMENTS
1. NAME AND ADDRESS OF HOSPITAL:			2. DATE(S) CONFINED FROM/TO IN THE PRIOR 2 YEARS.

TO BE COMPLETED BY THE ATTENDING PHYSICIAN

E. DESCRIPTION OF PATIENT’S RESTRICTIONS AND LIMITATIONS
1. Over the course of an 8 hour day, with 2 breaks stand 🞏 None 🞏 1-3 Hours 🞏 3-5 Hours 🞏 5-8 Hours and lunch, the patient can alternately: sit: 🞏 None 🞏 1-3 Hours 🞏 3-5 Hours 🞏 5-8 Hours walk: 🞏 None 🞏 1-3 Hours 🞏 3-5 Hours 🞏 5-8 Hours drive: 🞏 None 🞏 1-3 Hours 🞏 3-5 Hours 🞏 5-8 Hours
2. Patient can use upper extremities for repetitive: A. Simple Grasping B. Pushing/Pulling C. Fine Manipulation Right 🞏 Yes 🞏 No Right 🞏 Yes 🞏 No Right 🞏 Yes 🞏 No Left 🞏 Yes 🞏 No Left 🞏 Yes 🞏 No Left 🞏 Yes 🞏 No
3. Patient is able to: CONTINUOUS FREQUENT OCCASIONAL NO RESTRICTIONS 67-100% 34-66% 0-33% Bend (at waist) 🞏 🞏 🞏 🞏 Squat (at waist) 🞏 🞏 🞏 🞏 Climb 🞏 🞏 🞏 🞏 Reach above Shoulder 🞏 🞏 🞏 🞏 Kneel 🞏 🞏 🞏 🞏 Crawl 🞏 🞏 🞏 🞏 Use Feet (foot controls) 🞏 🞏 🞏 🞏 Drive 🞏 🞏 🞏 🞏 4. In an 8 hour day patient can lift/carry: 🞏 10 lbs. maximum and occasionally carry small objects: SEDENTARY WORK 🞏 20 lbs. maximum and frequently lift/carry up to 10 lbs.: LIGHT WORK 🞏 50 lbs. maximum and frequently lift/carry up to 25 lbs.: MEDIUM WORK 🞏 100 lbs. maximum and frequently lift/carry up to 50 lbs.: HEAVY WORK 🞏 In excess of 100 lbs. and frequently lift/carry 50 lbs.: VERY HEAVY WORK
F. PHYSICIAN COMPLETES IF LIMITATIONS ARE MENTAL/NERVOUS IN NATURE
TO WHAT DEGREE, IF ANY, ARE THE FOLLOWING CAPACITIES AFFECTED? CAPACITY NOT LIMITED MODERATELY LIMITED EXTREMELY LIMITED Ability to relate to other people beyond giving and receiving instructions 🞏 🞏 🞏 Ability to complete and follow instructions 🞏 🞏 🞏 Ability to perform simple and repetitive tasks 🞏 🞏 🞏 Ability to perform complex and varied tasks 🞏 🞏 🞏 In your opinion, does the claimant possess the mental capacity to understand his/her financial affairs and to direct the use of his/her funds? 🞏 Yes 🞏 No
G. PHYSICIAN COMPLETES ONLY IF THE CONDITION IS CARDIAC IN NATURE
Functional Capacity 🞏 Class 1 (no limitation) 🞏 Class 2 (slight limitation) (American Heart Association) 🞏 Class 3 (marked limitation) 🞏 Class 4 (complete limitation)
H. PHYSICIAN COMPLETES FOR ALL CONDITIONS: PROGNOSIS FOR RECOVERY
1. HAS THE PATIENT ACHIEVED MAXIMUM MEDICAL IMPROVEMENT? 🞏 Yes 🞏 No 2. IF YES, AS OF WHAT DATE CAN PATIENT RETURN TO WORK? / / MTH DAY YR 3. IF NO, WHEN DO YOU EXPECT PATIENT WILL ACHIEVE MAXIMUM MEDICAL IMPROVEMENT? 🞏 <2 weeks 🞏 <4 weeks 🞏 <2 months 🞏 3-4 months 🞏 5-6 months 🞏 6-8 months 🞏 <12 months 🞏 <16 months
4. WHEN THE ABOVE CHANGE OCCURS, WHAT FUNCTIONAL CAPACITY WILL THE PATIENT RECEIVE? 🞏 FULL RECOVERY 🞏 IMPROVED OVER CURRENT BUT NOT FULL 🞏 REMAIN AT PRESENT
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.
Your Name (Please Print)	Degree
Specialty	Telephone: ( ) Fax: ( )
Address (Please Print)
Physician’s Signature (no stamp)		Date

IMPORTANT: PLEASE ATTACH ALL MEDICAL RECORDS FROM THREE (3) MONTHS PRIOR TO DATE OF DISABILITY TO PRESENT.

IMPORTANT INFORMATION REGARDING APPLICATION FOR BENEFITS

ALABAMA, ARKANSAS and LOUISIANA — 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 for insurance is guilty of a crime and may be subject to fines and confinement in prison.

CALIFORNIA – For your protection California law requires the following to appear on this form. Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

COLORADO — 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.

FLORIDA — 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.

KENTUCKY — Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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.

MAINE — It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

MARYLAND — 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.

NEW JERSEY — Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

NEW MEXICO — 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 for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

NEW YORK (health insurance only) — 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.

OHIO — Any person who, with 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 is guilty of insurance fraud.

OKLAHOMA – WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

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.

PUERTO RICO – Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation with the penalty of a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the 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.

RHODE ISLAND — 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 for insurance is guilty of a crime and may be subject to fines and confinement in prison.

TENNESSEE, WASHINGTON — It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

VIRGINIA — 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 the state law.

WASHINGTON, DC — WARNING: 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.

Revised January 2022

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