Welcome John Smith
ABC Company


Electronic Claim Submission Instructions

Disability benefits usually stop when an employee returns to work. Be sure to notify The Standard immediately when an employee returns to work.

If you have any questions or problems regarding this submission or previous submissions, contact our customer service line at .

* Denotes a required field.

Submission Type
     Correction
Claim Type
Employer Information
Employer Name *
 Policy Number *
Street Address *
 Location Code
City *
 State *
 ZIP Code *
-

Contact Information (individual submitting claim)
Name *
Phone Number *
-- 		E-mail *
 
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Employee Information
Last Name *
 First Name *
 Middle Name
 
Street Address *
City *
 State *
 ZIP Code *
-
 
Phone Number *
--
 
Social Security Number *
-- 		Job Title *

Claim Information
1. Date employed * //
 
2. Is employee insured for
 
  Short Term Disability (STD)? *
 
        If yes, effective date //
 
  Long Term Disability (LTD)? *
 
        If yes, effective date //
 
  Group Life through The Standard? *
 
  Executive Benefits? *
 
3. Is disability work-related? *
 
4. Employee has filed for * (Select all that apply, and specify the weekly amount awarded.)
 
  Weekly Amount
   None
   Workers' Compensation
   State Disability
   Subrogation
   Social Security
   Retirement or pension
   Unknown
   Other (specify below)
 
        If other, specify
 
5. Employee's earnings *
 
  Earning period *
 
        If other, specify
 
  Date of last increase * //
 
  Earnings prior to increase *
 
6. Has employee ceased to work? *
 
        Last active day at work //
 
  Is employee scheduled for termination? *
 
        Termination date //
 
        Reason for termination
 
7. Job status when disability began *
 
  Hours/week *
 
8. Date employee returned to work //
 
9. Last day through which sick leave benefits
were paid by employer		 //
 
10. Last day through which any compensation
was paid by employer		 //
 
  Type of compensation
 
        If other, specify

Tax Information
1. Employee is subject to
 
2. Percentage of premium paid by employer
 
  STD premium %
 
  LTD premium %
 
3. Are employee premiums paid with pre-tax dollars (IRC Section 125 cafeteria plans)? *

Additional Information

Some states require The Standard 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. By submitting this form, you acknowledge that you have read the state specific fraud notices.