Unformatted text preview: Clear Form HARTFORD LIFE INSURANCE COMPANY
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY
HARTFORD LIFE GROUP INSURANCE COMPANY
APPLICATION FOR LONG TERM DISABILITY INCOME BENEFITS
This application package is divided into three sections, as follows:
Section I Employee's Statement - to be completed by the employee who is applying for Long
Term Disability benefits. Please attach a copy of the employee's driver's license. Section II Authorization to Obtain Information - to be signed by the employee. Section III Attending Physician's Statement - to be completed by the physician who is treating
the employee. PLEASE SEE THAT ALL SECTIONS ARE FULLY COMPLETED AND SIGNED. FORWARD THE
COMPLETED APPLICATION TO YOUR HARTFORD BENEFIT MANAGEMENT SERVICE CENTER. LC-4571-18 WalMart (Printed in U.S.A.) Ed 09-30-2005 APPLICATION FOR LONG TERM DISABILITY INCOME BENEFITS To Be Completed by the Employee
( BE SURE TO ANSWER ALL QUESTIONS A. Information about you
Last name HARTFORD LIFE INSURANCE COMPANY
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY
HARTFORD LIFE GROUP INSURANCE COMPANY Section I FAILURE TO DO SO MAY DELAY YOUR CLAIM )
First Middle Initial Address (Street) Social Security Number City State/Province Zip Telephone Number
Date of Birth (Month, Day, Year) Height Weight Male Your employer (include division, if applicable) Single Widowed Female Married Divorced Occupation When your disability began, did you have more than one employer (includes self-employment)?
No If "Yes," please provide
the name, address and phone number of that employer. Indicate the dates when you worked (or were self-employed). Please indicate the extent of your formal education (Circle one)
High School: 1 2 3 4 5 6
7 8 9 10 11
Trade School: 12 Masters Ph.D. Current Occupational Licenses: Briefly describe your past work experience for the last 20 years (Begin with your most recent job.)
Job Title Duties Years Worked (a)
(c) Now, or at some time in the future, would you be interested in seeking rehabilitation to some other kind of work?
Have you contacted your State Department of Vocational Rehabilitation?
telephone number of your counselor: Yes Yes No No If "Yes," please include the name, address and B. Information About your Family (required to determine your eligibility for Social Security Benefits)
Spouse's Name (Last, first)
Spouse's Social Security Number
Do you have any children under Age 19? Date of Birth (Month, Day, Year)
Yes Is your spouse employed?
Yes No No If "Yes," please provide the information requested below for each child. Name Date of Birth Social Security Number Name Date of Birth Social Security Number Name Date of Birth Social Security Number Do you have any children with disabilities(regardless of age)?
each child. Yes $ No If "Yes," please provide the information requested below for Name Date of Birth Social Security Number Name Date of Birth Social Security Number C. Information About the Condition Causing Your Disability
1a. For illness, answer the following questions:
What were your first symptoms?
When did you first notice them?
LC-4571-18 WalMart Have you had this illness before?
-1- Yes $ No If so, when?
Ed 09-30-2005 C. Information About the Condition Causing Your Disability (cont'd...)
1b. Next to any Activity of Daily Living (ADL), please place the number shown next to the statement that most accurately reflects your ability/
/inability to perform each: 1 = I can perform this activity independently; 2 = I can perform this activity with the use of equipment or
adaptive devices; 3 = I cannot perform this activity.
( ) Bathe (tub, shower, or sponge)
) Toilet ( ) Transfer from Bed to Chair ( ) Voluntary bladder and bowel control or ability to maintain a reasonable level of personal hygiene.
( ) Feed yourself with food that has been prepared and made available to you.
If you indicated (3) for any of the above activities, please describe the impairment and restrictions to your functionality that preclude you
from performing the activity.
( Height: Weight: Have you suffered a severe Cognitive Impairment that renders you unable to perform common tasks, such as using the phone, money
management, or medication management?
No If "Yes," describe:
2. For an injury, answer the following questions:
When, where and how did the injury occur?
3. For Illness, Injury or Pregnancy, answer the following questions:
Date you were first treated by a
Name of Physician
Address of Physician
(Month Day Year) Before you stopped working, did your condition require you to change your job, or the way you did your job? Yes No If "Yes," explain: What aspect of your condition made you unable to work?
Is your condition related to your occupation? Yes No If "Yes," explain: Have you filed, or do you intend to file a Workers' Compensation claim?
D. Information About the Disability
Last day you worked before the
Did you work a full day?
(Month Day Yes No No If "No," explain: Date you were first unable to work
(Month Year) Since that date, have you done any work?
No If "Yes," please
indicate dates worked, name of employer, and amount earned. Day Year) If you have not returned to work, do you expect to?
Yes Part time (date)
Full time (date)
No E. Information About Physicians and Hospitals
First medical attention for the current disability was given by (complete below)
Address (Street, CIty, State, Zip) ) Specialty
to List all Physicians and Hospitals you have seen for this condition (attach separate sheet, if needed)
Address (Street, CIty, State, Zip) Specialty
Dates seen to Hospital
Address (Street, CIty, State, Zip) Dates seen
to Have you consulted any other physicians or been hospitalized in the past three years?
If "Yes," complete the following concerning your past treatment (attach separate sheet, if needed)
Address (Street, City, State, Zip) Specialty
Address (Street, City, State, Zip)
LC-4571-18 WalMart No Dates of Confinement
-2- Ed 09-30-2005 F. Other Income APPLICATION FOR LONG TERM DISABILITY INCOME BENEFITS Check the other income benefits you have received/are receiving, or are eligible to receive during your disability
(complete the information requested).
Source of Income Amount(week /month) Social Security/Retirement $___________ / ______ Income from Work $___________ / ______ Workers' Compensation $___________ / ______ State Disability $___________ / ______ Pension/Retirement $___________ / ______ Pension/Disability $___________ / ______ Short Term Disability $___________ / ______ Unemployment $___________ / ______ No-Fault Insurance $___________ / ______ Other (include Individual or Group benefits) Date Payments ended $___________ / ______ Sick Pay or Salary Continuation Date Payments began $___________ / ______ Social Security/Disability Date Claim was filed $___________ / ______ G. Information about Tax Withholding
Federal law requires us to withhold federal income tax from your check if you request us to do so. We are also required to
send a report to your employer at the end of each calendar year showing your name, total amount of benefits paid to you, total
amount withheld, if any, and your social security number. If you want us to withhold tax, please indicate on the line below the
dollar amount to be withheld per benefit check. Whole dollars only (minimum is $87.00 per month): $
.00. LC-4571-18 WalMart -3- Ed 09-30-2005 H. Signature APPLICATION FOR LONG TERM DISABILITY INCOME BENEFITS With the exception of any source(s) of income reported above in Section F of this form, I certify by my signature that I have not
received and am not eligible to receive any source of income, except for my Hartford Disability Income. Further, I understand that
should I receive income of any kind or perform work of any kind during any period The Hartford has approved my disability claim,
I must report all details to The Hartford, immediately.
If I receive disability benefits greater than those which should have been paid, I understand that I will be required to provide a
lump sum repayment to the insurance company. The insurance company has the option to reduce or eliminate future disability
payments in order to recover any overpayment balance that is not reimbursed. For residents of all states EXCEPT California, Florida, New Jersey, Colorado, Pennsylvania, Arkansas, New
Mexico, Louisiana, New York, Oregon, Virginia and Puerto Rico: A person commits a fraudulent insurance act
if that person knowingly, and with intent to defraud any insurance company or other person, either: (a) files an application
for insurance or statement of claim containing any materially false information, or (b) conceals information concerning any
material fact in order to obtain an insurance policy or a benefit under an insurance policy. A fraudulent insurance act is
a crime. The Hartford shall pursue prosecution of any fraudulent insurance act to the fullest extent of the law.
For residents of Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a
statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the
For residents of New Jersey, Arkansas, and New Mexico: Any person who knowingly files a statement of claim
containing any false or misleading information is subject to criminal and civil penalties. Any person who includes any
false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
For residents of Pennsylvania: 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 a person to criminal and civil penalties.
For residents of Colorado: It is unlawful to knowingly provide false, incomplete, or misleading 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 its agent who knowingly provides false, incomplete, or misleading information to a
policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to an
insurance settlement or award shall be reported to the Colorado Division of Insurance.
FOR RESIDENTS OF CALIFORNIA: 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." For residents of Louisiana: Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to
fines and confinement in prison.
For residents of New 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 violation.
For residents of Puerto Rico: Any person who knowingly and with the intent to defraud, presents false information in
an insurance request form, or who presents, helps or has presented a fraudulent claim for the payment of a loss or other
benefit, or presents more than one claim for the same damage or loss, will incur a felony, and upon conviction will be
penalized for each violation with a fine no less than five thousand (5,000) dollars nor more than ten thousand (10,000)
dollars, or imprisonment for a fixed term of three (3) years, or both penalties. If aggravated circumstances prevail, the
fixed established imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail,
it may be reduced to a minimum of two (2) years.
The statements contained in this application for Long Term Disabiltiy Income Benefits are true and complete to the best of my
knowledge and belief. X X SIGNATURE OF THE EMPLOYEE DATE PLEASE ATTACH A COPY OF YOUR DRIVER'S LICENSE OR ANOTHER DOCUMENT THAT VERIFIES YOUR DATE OF BIRTH. LC-4571-18 WalMart -4- Ed 09-30-2005 APPLICATION FOR LONG TERM DISABILITY INCOME BENEFITS
Authorization to Obtain and Release Information Section II TO: Any physician, medical practitioner, hospital, pharmacy, clinic or other medical or medically-related facility or provider
of medical or dental services or supplies;
any employer, group policyholder, contract holder or insurer, benefit plan administrator, administrator, The Index
System, business entities, financial institutions, consumer reporting agencies, educational institutions, or
any Federal, State or Local Government Agency, including Social Security Administration and Veterans Administration.
I authorize you to release and send to: (i) Hartford Fire Insurance Company, Hartford Life Insurance Company, Hartford Life
and Accident Insurance Company, Hartford Life Group Insurance Company, and any affiliate of one or more of these four
companies, known collectively as The Hartford; or (ii) The Hartford's representatives, a complete copy of any and all of the
following information, records or documents relative to
Insured's Name (Please print.)
(Date of Birth) (Social Security Number) 1. Any and all medical information, including x-ray films, photocopies of medical records, medical histories, physical,
mental or diagnostic examinations, and treatment notes. For purposes of this authorization, medical information
specifically includes confidential information regarding HIV/AIDS, communicable diseases, alcohol or drug abuse,
and mental health, as such information may relate to my claim for benefits.
2. Work information and history, including, but not limited to, job duties, earnings and personnel records, client lists,
any and all other work-related information for contractual work performed; information on any insurance coverage
and claims filed, including all records and information related to such coverage and claims; credit information,
including, but not limited to, credit reports and credit applications; other financial information, e.g., Pension Benefits,
bank records; business transactions of any kind or description, including billing, invoices or payment records of any
kind; and academic transcripts.
3. Information concerning Social Security benefits, including, but not limited to, monthly benefit amounts, monthly
payment amounts, entitlement dates, and information from my Master Beneficiary Record.
I understand that the information obtained by use of the Authorization will be used for the purpose of evaluating and
administering a claim for benefits. Any information obtained will not be released by The Hartford to any person or
organization EXCEPT to reinsuring companies or their representatives, The Index System, physicians who have treated
me, or other persons or organizations performing business or legal services in connection with my Claim, or as may be
otherwise lawfully required, or as I may further authorize, or as may be necessary to prevent or to detect the perpetration
of a fraud.
I know that I may request to receive a copy of this Authorization.
This Authorization is given in connection with a claim for benefits. I intend that it be valid for the duration of the claim.
A photocopy or facsimile of this authorization shall be valid as the original. Relationship to Insured (if signed by Guardian) Signature of Insured or Guardian Date
LC-4571-18 WalMart -5- Ed 09-30-2005 APPLICATION FOR LONG TERM DISABILITY INCOME BENEFITS
Attending Physician's Statement of Disability
To be completed by the Employee Section III Name of patient
Address of patient Social Security Number
Street City Employer's name (and division, if applicable) D.O.B
State or Province ZIp Code or Postal Code SIgned (Patient) I hereby authorize release of information on this form by the below
named physician for the purpose of claim processing. Date: To be completed by the Attending Physician (The patient is responsible for the completion of this form without expense to the Company.) Patient's condition is the result of: Illness Injury If pregnancy, what is the expected date of delivery? Pregnancy Month Day Is condition due to illness or an injury that is work related? Yes Height Weight Year No DIAGNOSIS
Primary diagnosis: ICD-9 Code: Secondary diagnosis(es): ICD-9 Code(s): Subjective symptoms:
Test Results (list all results, or enclose test):
Test: Date: Results: Test: Date: Results: Physical examination findings: If pregnancy, indicate LMP date: Month Day Year TREATMENTS
Date you first treated this patient: Date you first treated this patient for this condition: Date of onset of this condition: Date of most recent treatment: How often has patient been seen/treated? Date of next office visit:
Yes Has patient been referred to any other physician? No If "Yes," Date(s) Name and address:
Nature of treatment for this condition: Has surgery been performed? :
If "Yes," Date: Yes No Procedure: Was patient hospitalized for this condition? CPT Code:
Yes No If "Yes," Date(s) admitted: Name and address of hospital(s): Progress (Please check one.):
LC-4571-18 WalMart Date(s) discharged: Recovered Improved
-6- Unchanged Retrogressed
Ed 09-30-2005 APPLICATION FOR LONG TERM DISABILITY INCOME BENEFITS
Attending Physician's Statement of Disability (page two)
If the patient's ability to perform any of the following activities is limited by his/her disorder, please describe the extent of the limitation and
its expected duration.
Standing: Walking: Sitting: Lifting / carrying: Reaching/working overhead: Pushing: Pulling: Driving:
Keyboard use/repetitive hand motion: If any other activities are limited, please specify the activities and the limitations: If the patient's vision is impaired, please describe the extent of the impairment: Do you believe the patient is competent to endorse checks and direct the use of the proceeds thereof? Yes No What is the psychiatric impairment (if applicable)?
Inadequate information to make assessment.
Slight difficulty in occupational functioning, but generally functioning well. Has some meaningful interpersonal relationships.
Moderate impairment in occupational functioning. Limited in performing some occupational duties.
Major impairment in several areas -- work, family relations. Avoidant behavior, neglects familiy, is unable to work.
Inability to function in almost all areas.
Date patient became unable to work due to this impairment? Month
If physical or psychiatric limitations exist, how long do you feel limitations will last?
Attending Physician's Name: (Please print or type.) Year Telephone # FAX # License No.
SS# or E.I.N.#: Degree: Specialty Street Address: City: State: Signature:
LC-4571-18 WalMart Zip Code: Date signed:
-7- Ed 09-30-2005 ...
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- Spring '12
- Chemistry, Social Security number, attending physician, Ed 09-30-2005