SHORT AND LONG TERM DISABILITY, LIFE INSURANCE, & DISABILITY PENSION CLAIMS

Are you unable to perform most of the duties of your occupation full time? Yes No

Do you have a sickness or injury that prevents you from working? Yes No

Do you know if you are covered by short or long term disability (STD or LTD), life insurance, pension plan? Yes No

(Some life plans provide a disability benefit, dismemberment benefit, or advance payment for terminal conditions. Some pension plans have a disability benefit provision)

Do you have recent paycheck stubs showing a deduction/contribution for LTD, STD, life insurance, or pension? Yes No

Do you have a copy of documents given to you when you were hired that might reference these or other benefits? Yes No

Do you have a copy of the policy or summary plan description for STD, LTD, life insurance, or pension? Yes No

Does your employer have a website that references benefits? (Do a Google search) Yes No

Is your employer a governmental entity or a church entity? (This may take it out of ERISA.) Yes No

Have you now or previously filed a claim for STD, LTD, dismemberment, or disability pension? Yes No

Do you have any letters from an insurance company or pension plan? Yes No

Did your employer give you a notice of your right to continue your life insurance or converted to a private policy? Yes No

A. If your Disability plan is fully-insured, state the name of the Carrier:

C. List the medical providers / therapists who are currently treating you for this condition. For each provider / therapist, state their name, address, contact person, telephone number, specialty, and the condition for which they provide treatment:
1 2 3

D. Have you filed a Claim for Disability benefits? Yes No

F. If “Yes,” what is the date of the Claim Denial?

G. In the space provided and in three or four sentences, please describe in your own words why the insurance company denied your Claim:

H. If your response to Question E is “No,” what is the date of your Claim?

I. Have you filed an Appeal of a Denied Claim? Yes No

K. If “Yes,” what is the date of the Appeal Denial?

L. In the space provided and in three or four sentences, please describe in your own words why the insurance company denied your Appeal:

M. Are you receiving Social Security Disability benefits? Yes No

O. If “Yes,” as of what date did the monthly Social Security Disability start?

P. Have you submitted a written request for documentation? Yes No

Q. Are you taking prescription medications for your condition(s)? If so, please list each such mediation, the dosage, for what conditions / symptoms you’re taking it, and any side-effects you’re experiencing.

R. In the space provided, please describe in your own words what your disability case is all about:

C. If “Yes,” what is the date of the Claim Denial?

D. In the space provided and in three or four sentences, please describe in your own words why your Claim was denied:

F. Have you filed an Appeal of a Denied Claim? Yes No

H. If “Yes,” what is the date of the Appeal Denial?

I. In the space provided and in three or four sentences, please describe in your own words why your Appeal was denied:

C. If “Yes,” what is the date of the Claim Denial?

D. In the space provided and in three or four sentences, please describe in your own words why your Claim was denied:

F. Have you filed an Appeal of a Denied Claim? Yes No

H. If “Yes,” what is the date of the Appeal Denial?

I. In the space provided and in three or four sentences, please describe in your own words why your Appeal was denied:

A. Please state the Florida government agencies you were employed by, and the years of employment (eg: City of Naples Streets & Stormwater Dep’t, 2002 – 2015, University of Florida, 2015 – 2019):

B. If your service with any of these Florida agencies was provisional rather than permanent, please indicate those years in which you were not permanent:

C. Please briefly describe your situation (attach additional sheets as necessary):

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SHORT AND LONG TERM DISABILITY, LIFE INSURANCE, & DISABILITY PENSION CLAIMS

SHORT TERM DISABILITY / LONG TERM DISABILITY

LIFE INSURANCE

LONG TERM CARE INSURANCE

FLORIDA RETIREMENT SYSTEM