DISABILITY CLAIM FOR ACCIDENT & SICKNESS …

1 Page 1 of 5A&S STD 5782 (03/15) Fs 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 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 1.

2 To Be Completed by the EmployerName of Employer Group Report #Sub-Code # (Sub-Division)Sub-Point # (Branch)Address City State Zip CodeSubsidiary or Division Name Contact Person s NamePhone # Contact Person s E-mail AddressFAX # Employee Name (First, MI, Last)Social Security ID #Date of HireJob TitleJob Class Sedentary Light Medium Heavy Very HeavyWork Location AddressWork Phone #Home Phone #Supervisor Name Supervisor s E-Mail AddressPhone #Is condition work related?

3 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. Date of CoverageBasic Earnings (exclusive of overtime, bonus, etc.)$ Hourly Weekly Bi-weekly Monthly AnnualPremium contributions Pre -TaxEmployer % Employee % Pos t-Tax Benefit AmountPayroll Classification Exempt Non-Exempt Salaried Hourly Union Non Union Other Employee s Status As Of Active VacationFirst Day Absent LOA Laid Off Terminated RetiredHours Worked Per Week

4 Full Time Part TimeScheduled Work Week M Tu W Th F Sa SuIs work week regular or variable If other than Active, please explain If STD buy up, date enrollment card signedLTD Coverage? Yes NoCan employee s job be modified/accommodated? Yes No If yes, please return to work been discussed with employee? Yes NoTo the best of your knowledge, indicate if the employee has filed for or is receiving income from any of the following sources.

5 Applied for Receiving $ Amount Frequency From/To DatesSalary Continuance/Sick Leave Workers Compensation State DISABILITY Other (Please identify) Provide weekly deduction amounts, if applicable.

6 Pre Tax Post Tax $ Weekly AmountMedical Life Dental LTD Other (Please identify) Authorizing SignatureDateMetropolitan Life Insurance Box 14590 Lexington, KY 40512 Fax: 1-800-230-9531 Page 2 of 5A&S STD 5782 (03/15) FsSection 2: To Be Completed by EmployeeName (First, MI, Last)Social Security #ID NumberDate 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?

7 Injury/ ACCIDENT ? If due to injury/ ACCIDENT , provide Date , Time AM PM Provide Details (Where and How)Is this condition work related? 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 From To

8 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 office 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? Yes NoPrimary Diagnosis Code . Diagnosis Secondary Diagnosis Code.

9 Diagnosis Objective Findings: CP T4 ProcedureDate If pregnancy, delivery date Expected Actual Type of delivery If patient has been hospitalized Inpatient Outpatient Admitted Discharged Treatment Plan: Additional Testing Medication Therapy Surgery Hospitalization Referral Other (Describe)Medications prescribed (names, dosages) Is patient able to work with job modifications or restrictions?

10 (please be specific): SignatureSpecialtyTax ID #Street Address City/State/Zip DateE-mail AddressTelephone #Fax #*Contact MetLife at 888-444-1433 for any questions you have on completing this services in connection with your DISABILITY CLAIM may be performed by our affiliate, MetLife Global Operations Support Center Private Limited.