In the event that your disability exceeds a continuous period of time in excess of 52 weeks and you are still unable to return to work, you are eligible to apply for Long Term Disability benefits. If approved, you will receive a monthly benefit, provided you continue to meet the definition of total disability. For more information pertaining to this benefit, eligibility, as well as the maximum duration and any offsets, please refer to this section of the HEALTH BENEFIT PLAN BOOKLET or contact the PLAN ADMINISTRATOR.
How to File a Claim
SEND CLAIM TO THE ADMINISTRATOR, DO NOT SEND CLAIM TO THE INSURANCE COMPANY.
To claim for Long Term Disability benefits please contact PLAN ADMINISTRATOR.
The form consists of the following sections:
(a) Attending Physician’s Statement
(b) Employer’s Statement
(c) Employee’s Statement
The Physician should complete the Attending Physician’s Statement portion of the form. He or she must clearly indicate his or her diagnosis, date(s) of service and type(s) of service rendered.
The Employer’s Statement should be completed by the employer. The date the Employee last worked must be shown on this form.