DISABILITY CLAIM FOR ACCIDENT & SICKNESS …

1 Page 1 of 4A&S STD LTD UNI 5782 (07/05) eF DISABILITY CLAIM FOR ACCIDENT & SICKNESS (A&S)/ SHORT TERM DISABILITY (STD)/SALARY CONTINUANCEI nstructions for completing the CLAIM form:1. Complete all applicable areas of the CLAIM form. Please print Please sign a) bottom of this page and b) Fraud Faxing this CLAIM form will expedite receipt and eliminate your need to mail 1: To Be Completed by the EmployerName of Employer Group Report #Sub-Code # (Sub-Division) Sub-Point # (Branch)Address City State Zip CodeSubsidiary or Division NameContact Person s NamePhone # Contact Person s E-mail AddressFAX # Employee Name (First, MI, Last)

2 Social Security ID #Date of HireJob TitleJob Class Sedentary Light Medium Heavy Very HeavyWork Location AddressWork Phone # Supervisor Name Supervisor s E-Mail AddressPhone # Is condition work related? Yes No. If yes, provide : W / C Carrier Name W/C Contact Person s Name Phone# Worker s Comp CLAIM # Date Last WorkedFirst Date of AbsenceDate Returned To Work Actual EstimatedEff.

3 Date of CoverageBasic Earnings (exclusive of overtime, bonus, etc.)$ Hourly Weekly Bi-weekly Monthly AnnualPremium contributions Pre-TaxEmployer % Employee % Post-Tax Benefi t AmountPayroll Classifi cation Exempt Non-Exempt Salaried Hourly Union Non Union Other Employee s Status As Of Active VacationFirst

4 Day Absent LOA Laid Off Terminated RetiredHours Worked Per Week Full Time Part TimeScheduled Work Week M Tu W Th F Sa SuIs work week regular or variable If other than Active, please explainIf STD buy up, date enrollment card signedLTD Coverage? Yes NoCan employee s job be modifi ed/accommodated? Yes No If yes, please return to work been discussed with employee?

5 Yes NoTo the best of your knowledge, indicate if the employee has fi led for or is receiving income from any of the following sources: Applied for Receiving $ Amount Frequency From/To DatesSalary Continuance/Sick Leave Workers Compensation State DISABILITY

6 Other (Please identify) Provide weekly deduction amounts, if applicable: Pre Tax Post Tax $ Weekly AmountMedical Life Dental LTD Other (Please identify) Authorizing SignatureDateMetropolitan Life Insurance Box 14590 Lexington, KY 40511-4590 Fax: 1-800-230-9531 Page 2 of 4A&S STD LTD UNI 5782 (07/05) eFSection 2.

7 To Be Completed by EmployeeName (First, MI, Last)Social Security #Date of Birth (MM/DD/YY) Gender M FAddress City State Zip CodeE-mail AddressHome Phone # Marital Status Married Single OtherFederal Tax Status Married SingleTax Exemptions (Number) Date DISABILITY BeganIs your DISABILITY due to Illness? Injury/ ACCIDENT ? If due to injury/ ACCIDENT , provide Date , Time AM PM Provide Details (Where and How)Is this condition work related?

8 Yes NoAutomobile Related? Yes NoName of physicians/providers who have treated you for this condition within the past 12 monthsName of Physician/Provider Phone Number Dates of Treatment Physician Specialty From To

9 From To Please describe what prevents you from performing the duties of your 3: To Be Completed by Attending PhysicianThis report is to assist us in making a DISABILITY determination that impacts income replacement for your patient. A MetLife CLAIM representative may telephone your offi ce if additional information is neededPatient NameDate DISABILITY BeganExpected Return to Work DateInitial date of treatment for this disabilityMost recent date of treatmentIs condition work-related?

10 Ye s NoPrimary ICD-9 . Diagnosis Secondary ICD-9 . Diagnosis Objective Findings: CPT4 ProcedureDate If pregnancy, delivery date Expected Actual Type of delivery If patient has been hospitalized Inpatient Outpatient Admitted Discharged Treatment Plan.