Standard Insurance Company
Employee Benefits Department 800.628.9696 Tel 800.437.0961 Fax
PO Box 2800 Portland OR 97208-2800
State of South Carolina
Long Term Disability Benefits Instructions
PLEASE READ CAREFULLY
The South Carolina long term disability (LTD) program consists of the employer-provided fully self-funded Basic LTD
plan number 627284 and the optional fully insured employee-paid Supplemental LTD plan under group policy
621144 issued by Standard Insurance Company. The Standard is acting only in an administrative capacity with respect
to the self-funded Basic LTD plan. The State of South Carolina is ultimately responsible for payment or non-payment
of claims under the self-funded Basic LTD plan. However, The Standard is ultimately responsible for payment or nonpayment of claims under the Supplemental LTD policy.
Welcome to Standard Insurance Company
We realize that being disabled is difficult. Even though you are unable to work, your financial obligations do not go away. To help
you through these difficult times, your employer has provided Basic LTD coverage for employees enrolled in the State Health
Insurance Plan or HMO plan. If you were eligible, enrolled and paid the required premiums, you may also have Supplemental
LTD coverage through Standard Insurance Company.
This packet contains the forms to apply for disability benefits under either State of South Carolina LTD plan. It also addresses
common questions about benefit claims. Please save this information for future reference.
Your application for benefits consists of four forms. Every space on these forms should be filled in to avoid delay in processing your
application. If a section does not apply, or information is not available, “NA” should be written in the space so that we know you did
not overlook that particular question. If a form is received incomplete, it may be returned for completion.
The four forms are:
1.
The Employee’s Statement
●
Answer every question completely. Be sure to use the appropriate section for injury, sickness or pregnancy. If a
question does not apply to you, write “NA”.
●
Use an additional page, if necessary, to give full and complete answers.
●
Attach copies of any Social Security, South Carolina Retirement System (SCRS), Workers’ Compensation, Leave
Pool (shared leave), sick leave or other benefit determinations you have received. If you have applied for any
other benefits but have not yet received them, please send a copy of the application receipt. This information is
needed to calculate accurately your monthly benefits. If you are unable to make copies of these documents,
please send the originals. We will photocopy and return them to you promptly.
●
Remember to sign and date your statement. An unsigned or undated statement will be returned to you.
2.
The Authorization to Obtain Information
The Authorization to Obtain Psychotherapy Notes
●
Please sign and date the Authorization to Obtain Information and attach it to the Employee’s Statement. Your
signature allows The Standard get the information about you that we need to determine your eligibility for
benefits. The Authorization to Obtain Information also allows The Standard to release this information to
certain state agencies.
●
If you have seen or been treated by a Psychiatrist, Psychotherapist, Psychologist, Clinical Social Worker (MSW,
MCSW, etc.), or any other provider of treatment for a mental condition, please sign and return the Authorization
to Obtain Information and the Authorization to Obtain Psychotherapy Notes.
You will receive copies of these Authorizations upon your request.
3.
The Attending Physician’s Statement
●
Part A should be completed by you.
●
Part B should be completed by your physician. If you have seen more than one physician for your disability, a
statement should be completed by each physician. (You may request additional forms from your employer.) Your
physician(s) should mail the completed form directly to The Standard.
4.
The Employer’s Statement
●
This first section (1) should be filled out by you. The rest of the form should be completed by your employer, who
will mail it to The Standard.
NOTE:
You are responsible for making sure the above listed forms are completed and returned to our office. After the completed
forms are received and evaluated by The Standard, further information may be necessary to make a decision on your
claim. If so, we will notify you with details. Should you have any questions, our office is here to assist you.
NOTE:
SI 3379-627284/621144
1 of 16
(8/05)
Standard Insurance Company
State of South Carolina
Long Term Disability Benefits Instructions
Claims Administrator 800.628.9696 Tel 800.437.0961 Fax
PO Box 2800 Portland OR 97208-2800
Long Term Disability Benefit Amount
If your LTD claim is approved, and you continue to be disabled as defined by the plan, Basic LTD benefits will be payable after the
benefit waiting period of 90 days from the date you became disabled is completed. The Supplemental LTD plan offers either a 90
day or 180 day benefit waiting period.
LTD benefits under the basic employer-provided plan are paid monthly at the lesser of 1) 62.5% of the first $1,280 of your
predisability earnings or 2) 62.5% of your predisability earnings less deductible income. Deductible income includes, but is not
limited to, SCRS disability and service retirement benefits, sick leave, salary continuation (including leave pool), Social Security
primary benefits, Workers’ Compensation, a portion of your earnings from work (if working while disabled), as well as income
received from or on behalf of a third party because of your disability, whether by judgment, settlement or other method.
If you are insured under the supplemental plan, Supplemental LTD benefits are paid monthly at 65% of your predisability
earnings (up to a monthly maximum benefit of $8000.00 for members disabled after 9/1/00, $6500.00 for those disabled before 9/1/00),
reduced by deductible income, including but not limited to SCRS disability and service retirement benefits, sick leave, salary
continuation (including leave pool), both primary and dependent Social Security benefits, Workers’ Compensation, a portion of
your earnings from work (if working while disabled), income received from or on behalf of a third party because of your disability,
and any benefits payable under the basic employer-provided LTD plan. This supplemental plan has a minimum benefit of
$100.00 per month.
It is your responsibility to apply promptly for all deductible income you may be eligible to receive. As some income sources have
strict application deadlines, please contact the income source directly for application details. Specifically, SCRS requires that
you must be still in service in order to apply for SCRS disability benefits. There may be an overpayment on your claim if The
Standard is not promptly informed that you are receiving income from other sources. Any overpayment must be repaid in full.
This can occur if other income is awarded retroactively.
Preexisting Conditions
Your LTD coverage has an exclusion for preexisting conditions that may affect your right to receive benefits. The exclusion will
apply if, during the 6 months before the effective date of your coverage, you consulted a physician, received medical treatment
or services, or took prescribed drugs or medications for a mental or physical condition and that condition causes or contributes to
your disability. However, this exclusion will not apply if:
1.
you have been continuously covered under the plan for 12 months prior to your date of disability, or
2.
a period of at least 12 consecutive months has elapsed since you last consulted a physician, received medical treatment
or services, or took prescribed drugs or medications for the preexisting condition, and your coverage became
effective during that period and remained continuously in effect until the date you became disabled.
Please consult your certificate or Insurance Benefits Guide for additional information regarding this or other exclusions and
limitations that may apply.
Payment of Benefits
If you qualify for LTD benefits, your monthly benefit checks will be mailed directly to the mailing address you provide to us.
Your benefit checks can be mailed directly to your bank account if you make your request in writing and provide a deposit slip
with your account number. Benefits are issued by the end of each month in which payments are due.
Tax Information
LTD benefits issued under the basic employer-provided plan are subject to Federal and State taxes. We will use the current W-4
form on file with your employer to determine the amount of your federal income tax deduction. We will also withhold a mandatory
7% in State income tax for South Carolina residents. State tax for other states may vary. Contact our office for details.
LTD benefits issued under the supplemental plan are not subject to Federal and State taxes if you pay the premiums with aftertax dollars.
For specific tax information and advice, you should consult your tax professional.
Questions:
For specific information about your LTD coverage, please refer to your Insurance Benefits Guide, Certificate of Coverage or
Certificate of Insurance. The group policy or plan document is the ultimate authority for all claims decisions. If you do not
have an Insurance Benefits Guide or certificate, you should contact your benefits administrator.
If Standard Insurance Company can be of service to you as you file your claim, please feel free to contact us. We look forward
to working with you.
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(8/05)
Standard Insurance Company
State of South Carolina
Long Term Disability Benefits
Employee’s Statement
Employee Benefits Department 800.628.9696 Tel 800.437.0961 Fax
PO Box 2800 Portland OR 97208-2800
Please type or print. (Form may be returned for unanswered questions.)
NOTE: Standard Insurance Company is acting only in an administrative capacity for the Basic LTD Plan.
1. CLAIMANT
Full Name:
Social Security No.:
Address:
City:
Phone No.: (
Sex:
)
˚ Male ˚ Female
State:
Birthdate:
Height:
Weight:
Dominant Hand:
Name of Spouse:
Zip Code:
˚ Right ˚ Left
Birthdate:
No. of Children under age 25:
Birthdate of Youngest:
Are you enrolled in the State Health Insurance Plan or HMO Plan (required for coverage under Basic LTD Plan) ?
Are you enrolled in the Supplemental LTD Plan and have you paid the required premiums?
Are you enrolled in another LTD Plan?
˚ Yes ˚ No
˚ Yes ˚ No
˚ Yes ˚ No
Name of Carrier:
Address:
Did you receive a Certificate of Coverage or Insurance for each effective coverage?
Insurance Benefits Guide?
˚ Yes ˚ No
˚ Yes ˚ No
If no, please contact your employer to obtain a copy.
2. EMPLOYMENT
Name of Agency/Institution:
Address:
Phone No.: (
City:
State:
Zip Code:
)
State your job title and describe your duties at work:
Is your disability work-related?
Have you filed a Workers’ Compensation claim?
˚ Yes ˚ No
˚ Yes ˚ No
Date of Injury:
If Yes, W.C. Claim No.:
Last full day at work:
Date you became unable to work at your occupation as a result of disability:
Are you now working or have you worked at your occupation or any other occupation since the date of your injury?
˚ Yes ˚ No
If yes, list names of employers, addresses, telephone numbers, and dates of employment.
Are you self-employed at any activity?
˚ Yes ˚ No
Monthly Earnings:
Date you resumed part-time work:
Work Phone: (
)
Extension:
Date you resumed full-time work:
Work Phone: (
)
Extension:
3. SICKNESS (Please list all illnesses which contribute to your being unable to work at your occupation.)
Illness:
Date First Noticed:
Date First Noticed:
State what you believe caused your illness:
Describe your symptoms:
Have you ever had the same condition or a related illness before?
SI 3379-627284/621144
˚ Yes ˚ No
Date:
3 of 16
(8/05)
Standard Insurance Company
State of South Carolina
Long Term Disability Benefits
Employee’s Statement
Claim Administrator 800.628.9696 Tel 800.437.0961 Fax
PO Box 2800 Portland OR 97208-2800
4. INJURY
Describe Injuries:
Cause of Injuries:
Time, Date and Location of Injuries:
5. PREGNANCY
Date you expect to cease work:
Expected delivery date:
Actual delivery date:
Expected return to work date:
Please indicate any foreseeable complications:
6. DISABILITY
Explain how your illness or injury prevents you from working at your occupation:
Do you feel a third party is responsible for your disability, or has made your condition worse?
˚ Yes ˚ No
If yes, please explain, giving name of third party.
Do you plan to bring a claim or lawsuit against this third party?
˚ Yes ˚ No
7. ATTENDING PHYSICIAN (List all physicians consulted for this injury or illness. Use separate sheet, if needed.)
Specialty:
Physician’s Name:
Phone No.: (
)
Address:
City:
Date First Consulted for this injury or illness:
Date Last Consulted:
Specialty:
Physician’s Name:
Phone No.: (
State:
)
Address:
City:
Date First Consulted for this injury or illness:
Date Last Consulted:
Specialty:
Physician’s Name:
Phone No.: (
Fax No.: (
Fax No.: (
State:
)
Address:
City:
Date First Consulted for this injury or illness:
Date Last Consulted:
Fax No.: (
State:
)
Zip Code:
)
Zip Code:
)
Zip Code:
8. HOSPITAL
Hospital Name:
Address:
From:
through:
Reason for hospitalization:
From:
through:
Reason for hospitalization:
9. HISTORY List all illnesses or injuries for which you have received treatment over the past five years. Use separate sheet if needed.
Ailment
SI 3379-627284/621144
Date
Medical Professional’s Name
Complete Address & Phone No.
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Standard Insurance Company
State of South Carolina
Long Term Disability Benefits
Employee’s Statement
Employee Benefits Department 800.628.9696 Tel 800.437.0961 Fax
PO Box 2800 Portland OR 97208-2800
10. DEDUCTIBLE INCOME
Have you applied for or are you receiving benefits from:
a. Social Security
˚
˚
c. Retirement or Pension (Employer, SCRS, ORP, etc.)
Please specify type
˚
d. Leave Pool or Shared Leave
˚
˚
˚
˚
˚
˚
˚
˚
˚
˚
˚
˚
˚
˚
˚
˚
˚
e. Third party income: weekly time loss, or from
judgment, settlement or other award
(related to current condition)
Short term or long term disability benefits from
another carrier
g. Other:
(e.g., unemployment or union benefits, etc.)
Receiving
Yes No
˚
˚
b. Workers’ Compensation
f.
Applied
Yes No
˚
˚
˚
Date Applied
For
Amount Received
Weekly
Monthly
Effective
Date
˚
˚
˚
Please send copies of any letters or notices you have now or receive in the future which approve or deny benefits, to allow us to properly calculate disability payments.
11. VOCATIONAL (Complete the following and/or attach a resume.)
Yes
Education Level
No
˚ ˚
Grade School Graduate
If no, last grade attended.
˚ ˚
˚ ˚
High School Graduate
GED
˚ ˚
College Graduate
˚ ˚
Post Graduate
Degree
Degree
Have you attended any trade schools or received other special training?
Major
˚ Yes
˚ No
Major
If yes, please describe.
Licenses or certificates?
˚ Yes ˚ No
If yes, please describe.
Work Experience: (Complete the following starting with your most recent work experience.)
Job Title & Employer
1.
SCRS Qualified?
Dates of Employment
From:
Duties
Last Salary
To:
2.
From:
To:
3.
From:
To:
4.
From:
To:
5.
From:
To:
Acknowledgment
I hereby certify that the answers I have made to the foregoing questions are both complete and true to the best of my knowledge and
belief. I acknowledge that I have read the applicable fraud notice on page 6 of this form.
SIGNATURE
SI 3379-627284/621144
DATE
5 of 16
(8/05)
Standard Insurance Company
State of South Carolina
Long Term Disability Benefits
Claim Form Fraud Notices
Employee Benefits Department 800.628.9696 Tel 800.437.0961 Fax
PO Box 2800 Portland OR 97208-2800
Some states require us to provide the following information to you:
CALIFORNIA RESIDENTS
For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or
fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
COLORADO RESIDENTS
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 the 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 RESIDENTS
Any person who knowingly and with intent to injure, defraud or deceive an insurance company, files a statement of claim or an
application containing false, incomplete or misleading information is guilty of a felony of the third degree.
NEW JERSEY RESIDENTS
Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil
penalties.
NEW YORK RESIDENTS
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 civil penalty not to
exceed five thousand dollars and the stated value of the claim for each such violation.
PENNSYLVANIA RESIDENTS
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.
ALL OTHER RESIDENTS
Some states require us to inform you that any person who knowingly and with intent to injure, defraud or
deceive an insurance company, or other person, files a statement containing false or misleading information
concerning any fact material hereto commits a fraudulent insurance act which is subject to civil and/or
criminal penalties, depending upon the state. Such actions may be deemed a felony and substantial fines
may be imposed.
SI 3379-627284/621144
6 of 16
(8/05)
Standard Insurance Company
State of South Carolina
Long Term Disability Benefits
Authorization to Obtain Information
Employee Benefits Department 800.628.9696 Tel 800.437.0961 Fax
PO Box 2800 Portland OR 97208-2800
I AUTHORIZE THESE PERSONS having any records or knowledge of me or my health:
●
Any physician, medical practitioner or health care provider.
●
Any hospital, clinic, pharmacy or other medical or medically related facility or association.
●
Any insurance or annuity company.
●
Any employer or plan sponsor.
●
Any organization or entity administering a benefit program or an annuity program.
●
Any educational, vocational or rehabilitational organization or program.
●
Any consumer reporting agency, financial institution, accountant, or tax preparer.
●
Any government agency (for example, Social Security Administration, Public Retirement System, Railroad Retirement Board, etc.).
TO GIVE THIS INFORMATION:
●
Charts, notes, x-rays, operative reports, lab and medication records and all other medical information about
me, including medical history, diagnosis, testing and test results. Prognosis and treatment of any physical or
mental condition, including:
●
Any disorder of the immune system, including HIV, Acquired Immune Deficiency Syndrome (AIDS) or
other related syndromes or complexes.
●
Any communicable disease or disorder.
●
Any psychiatric or psychological condition, including test results, but excluding psychotherapy notes.
Psychotherapy notes do not include a summary of diagnosis, functional status, the treatment plan, symptoms,
prognosis and progress to date.
●
Any condition, treatment, or therapy related to substance abuse, including alcohol and drugs.
and:
●
Any non-medical information requested about me, including such things as education, employment history, earnings
or finances, or eligibility for other benefits including retirement benefits and retirement plan contributions (for
example, Social Security Administration, Public Retirement System, Railroad Retirement Board, claims status, benefit amounts
and effective dates, etc.).
TO STANDARD INSURANCE COMPANY (THE STANDARD), AND IF BENEFITS ARE CLAIMED UNDER THE BASIC
EMPLOYER-PROVIDED LTD PLAN, THE INFORMATION MAY ALSO BE GIVEN TO THE STATE OF SOUTH CAROLINA,
EMPLOYEE INSURANCE PROGRAM AND VOCATIONAL REHABILITATION DEPARTMENT.
●
I acknowledge that any agreements I have made to restrict my protected health information do not apply to this
authorization, and I instruct the persons and organizations identified above to release and disclose my entire
medical record without restriction. I understand that The Standard will use the information to determine my
eligibility or entitlement for insurance benefits.
●
I understand and agree that this authorization shall remain in force throughout the duration of my claim for
benefits with The Standard. I understand that I have the right to refuse to sign this authorization and a right to
revoke this authorization at any time by sending a written statement to The Standard, except to the extent it has
been relied upon to disclose requested records. A revocation of the authorization, or the failure to sign the
authorization, may impair The Standard’s ability to evaluate or process my claim and may be a basis for denying my
claim for benefits.
●
I understand that in the course of conducting its business, The Standard may disclose to other parties information it
has about me. The Standard may release this information about me to a reinsurer, a plan administrator, or any person
performing business or legal services for The Standard in connection with my claim.
●
I understand that The Standard complies with State and Federal laws and regulations enacted to protect my privacy.
I also understand that the information disclosed to The Standard pursuant to this authorization may be subject to
redisclosure with my authorization or as otherwise permitted or required by law. (Disability coverage is not subject
to the Privacy Rules of the Health Insurance Portability and Accountability Act [HIPAA] and therefore the release
of information to The Standard is not protected under the Act.)
●
I acknowledge that I have read the authorization and the state variations (if applicable) on page 8. A photocopy or
facsimile of this authorization is as valid as the original and will be provided to me upon request.
Name (please print)
Social Security No.
Signature of Claimant/Representative
Date
If signature is provided by legal representative (e.g., Attorney in Fact, guardian or conservator), please attach documentation of
legal status.
This Authorization is a two-page document. Please see page 8 for additional terms and information. Both pages are part of the Authorization.
SI 3379-627284/621144
7 of 16
(8/05)
Standard Insurance Company
State of South Carolina
Long Term Disability Benefits
Authorization to Obtain Information
Employee Benefits Department 800.628.9696 Tel 800.437.0961 Fax
PO Box 2800 Portland OR 97208-2800
Some states require us to provide the following information to you and to those persons and entities disclosing information
about you:
FOR RESIDENTS OF MINNESOTA
This authorization excludes the release of information about HBV (Hepatitis B Virus), HCV (Hepatitis C Virus), or HIV
(Human Immunodeficiency Virus) tests which were administered (1) to a criminal offender or crime victim as a result of a
crime that was reported to the police; (2) to a patient who received the services of emergency medical services personnel at a
hospital or medical care facility; (3) to emergency medical personnel who were tested as a result of performing emergency
medical services. The term “emergency medical personnel” includes individuals employed to provide pre-hospital emergency
services; licensed police officers, firefighters, paramedics, emergency medical technicians, licensed nurses, rescue squad
personnel, or to other individuals who serve as volunteers of an ambulance service who provide emergency medical services;
crime lab personnel, correctional guards, including security guards, at the Minnesota security hospital, who experience a
significant exposure to an inmate who is transported to a facility for emergency medical care; and other persons who render
emergency care or assistance at the scene of an emergency, or while an injured person is being transported to receive medical
care and who would qualify for immunity under the good samaritan law.
FOR RESIDENTS OF NEW MEXICO
The state of New Mexico requires us to provide you with the following information pursuant to its Domestic Abuse Insurance
Protection Act.
The accompanying Authorization to Obtain Information allows Standard Insurance Company to obtain personal information as
it determines your eligibility for insurance benefits. The information obtained from you and from other sources may include
confidential abuse information. “Confidential abuse information” means information about acts of domestic abuse or abuse
status, the work or home address or telephone number of a victim of domestic abuse or the status of an applicant or insured as a
family member, employer or associate of a victim of domestic abuse or a person with whom an applicant or insured is known to have
a direct, close personal, family or abuse-related counseling relationship. With respect to confidential abuse information, you may
revoke this authorization in writing, effective ten days after receipt by The Standard, understanding that doing so may result in a
claim being denied or may adversely affect a pending insurance action.
The Standard is prohibited by law from using abuse status as a basis for denying, refusing to issue, renew or reissue or canceling
or otherwise terminating a policy, restricting or excluding coverage or benefits of a policy or charging a higher premium for a
policy.
Upon written request you have the right to review your confidential abuse information obtained by The Standard. Within 30
business days of receiving the request, The Standard will mail you a copy of the information pertaining to you. After you have
reviewed the information, you may request that we correct, amend or delete any confidential abuse information which you believe
is incorrect. The Standard will carefully review your request and make changes when justified. If you would like more information
about this right or our information practices, a full notice can be obtained by writing to us.
If you wish to be a protected person (a victim of domestic abuse who has notified The Standard that you are or have been a victim
of domestic abuse) and participate in The Standard’s location information confidentiality program, your request should be sent
to the same address above.
SI 3379-627284/621144
8 of 16
(8/05)
Standard Insurance Company
State of South Carolina
Long Term Disability Benefits
Authorization to Obtain Psychotherapy Notes
Employee Benefits Department 800.628.9696 Tel 800.437.0961 Fax
PO Box 2800 Portland OR 97208-2800
I AUTHORIZE THESE PERSONS having any records or knowledge of me or my health:
•
•
Any physician, medical practitioner or health care provider; and
Any hospital, clinic, or other medical or medically related facility or association.
TO GIVE THIS INFORMATION:
Notes recorded by a health care provider who is a mental health professional documenting or analyzing the contents of
conversation(s) during a private counseling session or a group, joint, or family counseling session and that are separated from
the rest of my medical record.
TO STANDARD INSURANCE COMPANY (THE STANDARD), AND IF BENEFITS ARE CLAIMED UNDER THE BASIC
EMPLOYER-PROVIDED LTD PLAN, THE INFORMATION MAY ALSO BE GIVEN TO THE STATE OF SOUTH CAROLINA,
EMPLOYEE INSURANCE PROGRAM AND VOCATIONAL REHABILITATION DEPARTMENT.
•
I acknowledge that any agreements I have made to restrict my protected health information do not apply to this authorization, and I instruct the persons and organizations identified above to release and disclose my entire medical record
without restriction. I understand that The Standard will use the information to determine my eligibility or entitlement
for insurance benefits.
•
I understand and agree that this authorization shall remain in force throughout the duration of my claim for benefits with
The Standard. I understand that I have the right to refuse to sign this authorization and a right to revoke this authorization at any time by sending a written statement to The Standard, except to the extent it has been relied upon to disclose
requested records. A revocation of the authorization, or the failure to sign the authorization, may impair The Standard’s
ability to evaluate or process my claim and may be a basis for denying my claim for benefits.
•
I understand that in the course of conducting its business, The Standard may disclose to other parties information it has
about me. The Standard may release this information about me to a reinsurer, a plan administrator, or any person
performing business or legal services for The Standard in connection with my claim.
•
I understand that The Standard complies with State and Federal laws and regulations enacted to protect my privacy. I
also understand that the information disclosed to The Standard pursuant to this authorization may be subject to redisclosure
with my authorization or as otherwise permitted or required by law. (Disability coverage is not subject to the Privacy Rules
of the Health Insurance Portability and Accountability Act [HIPAA] and therefore the release of information to The
Standard is not protected under the Act.)
•
I acknowledge that I have read the authorization and the state variations (if applicable) on page 10. A photocopy or
facsimile of this authorization is as valid as the original and will be provided to me upon request.
Name (please print)
Social Security No.
Signature of Claimant/Representative
Date
If signature is provided by legal representative (e.g., Attorney in Fact, guardian or conservator), please attach documentation of
legal status.
This Authorization is a two-page document. Please see page 10 for additional terms and information. Both pages are part of the Authorization.
SI 3379-627284/621144
9 of 16
(8/05)
Standard Insurance Company
State of South Carolina
Long Term Disability Benefits
Authorization to Obtain Psychotherapy Notes
Employee Benefits Department 800.628.9696 Tel 800.437.0961 Fax
PO Box 2800 Portland OR 97208-2800
Some states require us to provide the following information to you and to those persons and entities disclosing information
about you:
FOR RESIDENTS OF MINNESOTA
This authorization excludes the release of information about HBV (Hepatitis B Virus), HCV (Hepatitis C Virus), or HIV (Human
Immunodeficiency Virus) tests which were administered (1) to a criminal offender or crime victim as a result of a crime that was
reported to police; (2) to a patient who received the services of emergency medical services personnel at a hospital or medical
care facility; (3) to emergency medical personnel who were tested as a result of performing emergency medical services. The term
“emergency medical personnel” includes individuals employed to provide pre-hospital emergency services; licensed police
officers, firefighters, paramedics, emergency medical technicians, licensed nurses, rescue squad personnel, or other individuals
who serve as volunteers of an ambulance service who provide emergency medical services; crime lab personnel, correctional
guards, including security guards, at the Minnesota security hospital, who experience a significant exposure to an inmate who is
transported to a facility for emergency medical care; and other persons who render emergency care or assistance at the scene of
an emergency, or while an injured person is being transported to receive medical care and who would qualify for immunity under
the good samaritan law.
FOR RESIDENTS OF NEW MEXICO
The state of New Mexico requires us to provide you with the following information pursuant to its Domestic Abuse Insurance
Protection Act.
The accompanying Authorization to Obtain Information allows Standard Insurance Company to obtain personal information as
it determines your eligibility for insurance benefits. The information obtained from you and from other sources may include
confidential abuse information. “Confidential abuse information” means information about acts of domestic abuse or abuse
status, the work or home address or telephone number of a victim of domestic abuse or the status of an applicant or insured as a
family member, employer or associate of a victim of domestic abuse or a person with whom an applicant or insured is known to have
a direct, close personal, family or abuse-related counseling relationship. With respect to confidential abuse information, you may
revoke this authorization in writing, effective ten days after receipt by The Standard, understanding that doing so may result in a
claim being denied or may adversely affect a pending insurance action.
The Standard is prohibited by law from using abuse status as a basis for denying, refusing to issue, renew or reissue or canceling
or otherwise terminating a policy, restricting or excluding coverage or benefits of a policy or charging a higher premium for a
policy.
Upon written request you have the right to review your confidential abuse information obtained by The Standard. Within 30
business days of receiving the request, The Standard will mail you a copy of the information pertaining to you. After you have
reviewed the information, you may request that we correct, amend or delete any confidential abuse information which you believe
is incorrect. The Standard will carefully review your request and make changes when justified. If you would like more information
about this right or our information practices, a full notice can be obtained by writing to us.
If you wish to be a protected person (a victim of domestic abuse who has notified The Standard that you are or have been a victim
of domestic abuse) and participate in The Standard’s location information confidentiality program, your request should be sent
to the same address above.
SI 3379-627284/621144
10 of 16
(8/05)
Standard Insurance Company
State of South Carolina
Long Term Disability Benefits
Attending Physician’s Statement
Employee Benefits Department 800.628.9696 Tel 800.437.0961 Fax
PO Box 2800 Portland OR 97208-2800
NOTE: Standard Insurance Company is acting only in an administrative capacity for the Basic LTD Plan.
PART A. TO BE COMPLETED BY PATIENT
Full Name:
Social Security No.:
Other Names Used:
Address:
Phone No.: (
)
City:
State:
Birthdate:
Patient No.:
Zip Code:
Health Plan:
PART B. TO BE COMPLETED BY PHYSICIAN
DEAR DOCTOR: The purpose of this form is to help us determine whether the clinical condition of your patient is disabling. We need documentation
of functional impairment. Please include laboratory data and results of special tests (X-rays, CAT scan, EKG, etc.) Please attach copies of any pertinent
surgical reports, hospital admitting history, physician discharge summaries, chart notes, and narrative reports.
The patient is responsible for the completion of this form without expense to The Standard. (Forms may be returned due to unanswered questions.)
The following information is needed to document the Patient’s inability to work:
1. DIAGNOSIS
A. Primary Diagnosis:
ICDA Classification:
B. Secondary Diagnosis (related to patient’s disability):
C. Current Symptoms:
D. Objective findings (Clinical Exam, Imaging Studies, Lab Results):
E. Patient’s Height:
Weight:
Most recent blood pressure:
2. PREGNANCY (If applicable.)
Pulse:
˚ Yes ˚ No
˚ Vaginal ˚ Caesarean Section
Expected date of delivery:
Anticipated to be normal?
Actual date of delivery:
Type of delivery:
3. HISTORY
A. When did symptoms appear or accident happen?
B. Did you recommend to the patient to stop work?
˚ Yes ˚ No
If yes, as of what date:
Why?
If no, who recommended that the patient stop work?
C. Has the patient ever had the same or similar condition?
Describe:
D. Is the condition related to the patient’s employment?
˚ Yes ˚ No
If yes, when?
˚ Yes ˚ No ˚ Undetermined
˚ Yes ˚ No
E. Did you complete a Workers’ Compensation Report for this condition?
F. Who was the patient referred to you by:
4. TREATMENT
A. Date patient first consulted you for this condition:
, for any condition:
B. Dates of subsequent visits:
C. Date of most recent visit:
D. Treatment Plan (include surgery, physical therapy, psychiatric counseling):
E. Medications:
F. Response to Treatment Plan:
SI 3379-627284/621144
11 of 16
(8/05)
Standard Insurance Company
State of South Carolina
Long Term Disability Benefits
Attending Physician’s Statement
Claims Administrator 800.628.9696 Tel 800.437.0961 Fax
PO Box 2800 Portland OR 97208-2800
5. PHYSICAL CAPACITIES
A. Based on the patient’s physical limitations and restrictions, he/she can (circle the appropriate level of ability):
Frequently lift (in pounds):
50+
50
20
10
0
Maximum lift:
50+
50
20
10
0
Walk/Stand at one time (in hours):
8
7
6
5
4
3
2
Walk/Stand in an 8-hour work day:
8
7
6
5
4
3
2
Sit at one time (in hours):
8
7
6
5
4
3
2
Sit in an 8-hour work day:
8
7
6
5
4
3
2
Bend/Stoop: ˚ Never ˚ Occasionally ˚ Frequently
Fine Manipulation: Right: ˚ Yes
Grasp:
Left:
˚ Never ˚ Occasionally ˚ Frequently
˚ Yes
Reach:
˚ Never ˚ Occasionally ˚ Frequently
1
1
1
1
˚ No
˚ No
0
0
0
0
6. LEVEL OF FUNCTIONAL IMPAIRMENT
A. The patient is: ˚ Ambulatory ˚ House Confined ˚ Bed Confined ˚ Hospital Confined
B. Describe the patient’s mental and cognitive limitations and restrictions:
C. Is this patient competent to manage insurance benefits? ˚ Yes ˚ No
If no, is the patient competent to appoint someone to help manage the insurance benefits?
˚ Yes ˚ No
D. Other impairments (please be specific):
E. Dominant hand:
˚ Right ˚ Left
7. HOSPITALIZATION
A. Date admitted:
Date discharged:
Date surgical procedure performed:
B. Reason for admittance to hospital:
C. Describe nature of any surgical procedure performed:
D. Outcome:
Name of hospital:
Address:
City:
State:
Zip Code:
State:
Zip Code:
State:
Zip Code:
8. OTHER TREATING MEDICAL PROFESSIONALS (if known)
A. Name:
Specialty:
Address:
City:
B. Name:
Specialty:
Address:
City:
9. PROGNOSIS
A. Describe patient’s condition since onset of symptoms:
˚ Recovered ˚ Improved ˚ Not Changed ˚ Retrogressed
B. When do you expect a fundamental or marked change in patient’s condition?
˚ Unable to determine, follow up in
weeks
months
˚ Never
C. When do you anticipate the patient can return to work?
Full-time:
˚ Unable to determine, follow up in
Part-time:
weeks
months
˚ Never
(
hrs/day,
number days/weeks)
D. What reasonable work or job site modifications could the employer make to assist the individual to return to work?
E. Assessment and Treatment are complicated by:
˚ Malingering ˚ Significant exaggeration, inconsistent findings ˚ Dependence on drugs/medications
** Please send copies of chart notes, diagnostic, laboratory, and electrodiagnostic findings, as well as operative reports and hospital discharge summaries
for the past year.
Acknowledgment
I hereby certify that the answers I have made to the foregoing questions are both complete and true to the best of my knowledge and
belief. I acknowledge that I have read the applicable fraud notice on page 13 of this form.
Physician’s Signature:
Date:
Physician’s Name (Please print):
Specialty:
Address:
City:
Physician’s Taxpayer ID No.:
Phone No.: (
State:
)
Fax No.: (
Zip Code:
)
Return to Standard Insurance Company at the address above.
SI 3379-627284/621144
12 of 16
(8/05)
Standard Insurance Company
State of South Carolina
Long Term Disability Benefits
Claim Form Fraud Notices
Claims Administrator 800.628.9696 Tel 800.437.0961 Fax
PO Box 2800 Portland OR 97208-2800
Some states require us to provide the following information to you:
CALIFORNIA RESIDENTS
For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or
fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
COLORADO RESIDENTS
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 the 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 RESIDENTS
Any person who knowingly and with intent to injure, defraud or deceive an insurance company, files a statement of claim or an
application containing false, incomplete or misleading information is guilty of a felony of the third degree.
NEW JERSEY RESIDENTS
Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil
penalties.
NEW YORK RESIDENTS
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 civil penalty not to
exceed five thousand dollars and the stated value of the claim for each such violation.
PENNSYLVANIA RESIDENTS
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.
ALL OTHER RESIDENTS
Some states require us to inform you that any person who knowingly and with intent to injure, defraud or
deceive an insurance company, or other person, files a statement containing false or misleading information
concerning any fact material hereto commits a fraudulent insurance act which is subject to civil and/or
criminal penalties, depending upon the state. Such actions may be deemed a felony and substantial fines
may be imposed.
SI 3379-627284/621144
13 of 16
(8/05)
Standard Insurance Company
State of South Carolina
Long Term Disability Benefits
Employer’s Statement
Employee Benefits Department 800.628.9696 Tel 800.437.0961 Fax
PO Box 2800 Portland OR 97208-2800
Please type or print. Form may be returned for unanswered questions.
NOTE: Standard Insurance Company is acting only in an administrative capacity for the Basic LTD Plan.
1. EMPLOYEE
Full Name:
Social Security No.:
Address:
City:
Phone No.: (
)
State:
Zip Code:
Birthdate:
2. INFORMATION
Job Title:
Date Employed:
(Please attach a copy of position description.)
Employee’s work location (agency/institution):
Employee’s coverage effective date:
Group No.:
˚ State Basic LTD
˚ Supplemental LTD
Is employee currently insured with another carrier for disability coverage?
Did employee receive a certificate of coverage for each appropriate plan?
plan for covered employee when filing disability claim.)
˚ 90-day ˚ 180-day Benefit Waiting Period
Carrier:
˚ Yes ˚ No
˚ Yes ˚ No ˚ Don’t Know (Please forward Certificate of Coverage for State Basic LTD
Last day of work before disability commenced:
Date employee returned to work after disability ended:
˚ Yes ˚ No ˚ Undetermined
˚ Yes ˚ No Carrier Name:
Is medical condition due to employment?
Workers’ Compensation claim?
Claim No.:
Address:
Have you considered allowing the employee to work in another occupation, or to modify and/or alter the job duties of the current occupation?
˚ Yes ˚ No
Please explain:
˚ Yes ˚ No Effective date:
Is employee terminated? ˚ Yes ˚ No
Effective:
Is employment scheduled for termination? ˚ Yes ˚ No
On FMLA?
through:
Reason:
Effective:
Reason:
Hours worked per week before disability commenced:
Date sick leave benefits paid through:
Is Claimant on LWOP?
˚ Yes ˚ No
Salary continuation from:
Effective:
through:
through:
3. SALARY (Earnings as of last day worked before disability commenced)
Regularly paid
hours per week, excluding overtime.
Please check ONE:
$
˚ Basic Yearly Earnings
$
for
months per year
˚ Basic Monthly Earnings
$
for
months per year OR
˚ Basic Hourly Earnings
length of contract:
˚ Basic Contract Earnings $
˚ Commissions (Please attach list of commissions paid for the period specified in your Group Policy)
˚ Shift Differential
˚ Bonuses
Date of last increase:
Yearly employment schedule, indicate:
SI 3379-627284/621144
days per year
Earnings prior to increase: $
˚ 12-month period ˚ Other (i.e. contract days, 9 mos., etc.):
14 of 16
(8/05)
Standard Insurance Company
State of South Carolina
Long Term Disability Benefits
Employer’s Statement
Employee Benefits Department 800.628.9696 Tel 800.437.0961 Fax
PO Box 2800 Portland OR 97208-2800
4. DEDUCTIBLE INCOME
Is employee eligible for or now receiving
benefits from:
a. Optional Retirement Plan
Applied
Yes No
Yes
˚ ˚
˚
˚ ˚
˚ ˚
˚
˚ ˚
˚ ˚
˚
˚ ˚
Date of
Application
Receiving
No Don’t Know
Amount
Weekly
Monthly
Effective
Date
Acct. No.:
˚ TIAA/CREF or
˚ Other:
b. PORS
˚ ˚
c. SCRS
d. GARS
˚ ˚
e. JRS
f.
˚ ˚
Social Security
g. Workers’ Compensation
Claim No.:
h. Leave Pool or Shared Leave
i.
Other:
(e.g. short-term disability insurance, another
long-term disability plan, unemployment or union
benefits, etc.)
˚ ˚
˚ ˚
˚ ˚
˚ ˚
˚
˚ ˚
˚
˚ ˚
˚
˚ ˚
˚
˚ ˚
˚
˚ ˚
˚
If this employee does not belong to SCRS, please provide our office with the name and telephone number of the contact person for this employee’s retirement plan.
Person to contact:
Telephone: (
5. TAX INFORMATION
Is this employee subject to Social Security taxes?
)
˚ Yes ˚ No
If yes, what are the employee’s year-to-date Social Security wages?
If the employee has Supplemental LTD Coverage:
What percentage of the Supplemental LTD premium does the employer pay?
%
the employee pay?
%
˚ Yes ˚ No
˚ Yes ˚ No
Are Supplemental LTD premiums paid with pre-tax dollars under a Section 125 or cafeteria plan?
Has this Supplemental LTD contribution percentage changed within the last three years?
Employer’s Federal Tax ID Number:
6. ATTACHMENTS (Please check and attach copies of the following)
˚ Employee’s current W-4 form, include withholding allowances
˚ The 2 most current Notice of Election forms with signed authorization that verifies Health Plan enrollment for at least 1 year or for the duration of coverage, whichever is less
˚ Supplemental LTD Enrollment form(s), including refusal of coverage if applicable
˚ Job class specification and position description
˚ Employment Application or Resume
˚ Deductible Income Documents (Social Security, Workers’ Compensation, SCRS, etc.) if available
7. EMPLOYER REPRESENTATIVE COMPLETING THIS FORM
Employer:
Phone No.:
Policy No.:
Address:
City:
State:
Zip Code:
Acknowledgment
I hereby certify that the answers I have made to the foregoing questions are both complete and true to the best of my knowledge and
belief. I acknowledge that I have read the applicable fraud notice on page 16 of this form.
Signature:
Date:
Prepared by:
Phone No.: (
SI 3379-627284/621144
Title:
)
Fax No.: (
15 of 16
)
(8/05)
Standard Insurance Company
State of South Carolina
Long Term Disability Benefits
Claim Form Fraud Notices
Employee Benefits Department 800.628.9696 Tel 800.437.0961 Fax
PO Box 2800 Portland OR 97208-2800
Some states require us to provide the following information to you:
CALIFORNIA RESIDENTS
For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or
fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
COLORADO RESIDENTS
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 the 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 RESIDENTS
Any person who knowingly and with intent to injure, defraud or deceive an insurance company, files a statement of claim or an
application containing false, incomplete or misleading information is guilty of a felony of the third degree.
NEW JERSEY RESIDENTS
Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil
penalties.
NEW YORK RESIDENTS
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 civil penalty not to
exceed five thousand dollars and the stated value of the claim for each such violation.
PENNSYLVANIA RESIDENTS
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.
ALL OTHER RESIDENTS
Some states require us to inform you that any person who knowingly and with intent to injure, defraud or
deceive an insurance company, or other person, files a statement containing false or misleading information
concerning any fact material hereto commits a fraudulent insurance act which is subject to civil and/or
criminal penalties, depending upon the state. Such actions may be deemed a felony and substantial fines
may be imposed.
SI 3379-627284/621144
16 of 16
(8/05)
