Transcription of Standard Insurance Company Disability Insurance PO Box ...
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Standard Insurance Company Disability Insurance PO Box ...
SI 2047-ER 1 of 2 (3/18)4. Has the employee filed for: Workers Compensation w Yes w No State Disability w Yes w No Other w Yes w No Weekly Amount 5. Employee s Earnings $ _____ Check one w Hourly w Weekly w Monthly w Annual w Commission w Other w Shift Differential w Bonuses Date of last increase _____ Earnings prior to increase $ _____6. Last active date at work7. Job status when Disability began:8. Date employee returned to work9. Last date through which sick leave benefits were paid by employer10.
SI 2047-ER 2 of 2 (3/18) Disability Insurance Claim Form Fraud Notices Standard Insurance Company 800.368.2859 Tel 800.378.6053 Fax PO Box 2800 Portland OR 97208 Some states require us to provide the following information to you:
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