New York Life Form 22025 Insurance Continued Disability Waiver Benefits
500385 Rev. 04/2021
DIVISION
Date:
REASONIF YES, DATE
NAME OF EMPLOYER / ASSOCIATION
EMPLOYER / ASSOCIATION
Group/Association - Short Term Disability Benefits
Print: Signature:
HAS EMPLOYEE/MEMBER BEEN TERMINATED?
IF YES, DATE
EMPLOYER'S / ADMINISTRATOR'S CERTIFICATION
PAID THRU DATEGROSS WEEKLY AMOUNT DATE BEGANBENEFIT
LAST DAY WORKED DATE RETURNED TO WORK PREMIUM PAID THROUGH DATE
% OF INSURED'S CONTRIBUTION
TO PREMIUM
# of Hours:
PLEASE LIST ALL BENEFITS THAT THE INSURED IS RECEIVING OR ELIGIBLE TO RECEIVE AS A RESULT OF HIS/HER DISABILITY (E.G. SALARY CONTINUANCE, SICK PAY,
STATE DISABILITY, WORKERS' COMPENSATION, ETC.).
TO BE COMPLETED BY THE EMPLOYER / ADMINISTRATOR
NAME OF EMPLOYEE/ASSOCIATION MEMBER (Last Name) (Middle Initial) DATE OF BIRTH SEXSOCIAL SECURITY NO.(First Name)
Pre-Tax Basis
Post-Tax Basis
EMPLOYEE'S / MEMBER'S CONTRIBUTIONS WERE MADE ON:
If Yes, Attach Copy
WAS INSURANCE ISSUED ON THE BASIS OF A STATEMENT OF PHYSICAL CONDITION?
BASIC EARNINGS PER WEEK
PLEASE CHECK THE APPROPRIATE BLOCKS REGARDING THE INSURED'S EMPLOYMENT STATUS.
OCCUPATIONPOLICY NO.
( )
TELEPHONE #(Zip Code)(State)ADDRESS (Street) (City)
Hrs./wk
DATE OF LAST CHANGE IN EARNINGS DATE HIRED / MEMBER OF ASSOCIATION EFFECTIVE DATE OF INSURANCE
HAS EMPLOYEE/MEMBER BEEN LAID OFF? REASON
MAIL OR FAX TO:
TELEPHONE #(Zip Code)(State)ADDRESS (Street) (City)
( )
FM
Part-time
Full-time
Hourly
SalariedManagementExempt Supervisory Union Local #
Non-UnionNon-SupervisoryNon-ManagementNon-Exempt
No Yes
No Yes
No Yes
NEW YORK FRAUD WARNING: 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 $5000 and the stated
value of the claim for each such violation.
For residents of the following states, please see the last page of this form: California, Colorado, District of Columbia, Florida, Kansas, Kentucky,
Louisiana, Maryland, Minnesota, New Jersey, Oregon, Pennsylvania, Puerto Rico, Rhode Island, Tennessee, Texas, Virginia or Washington.
Life Insurance Company of North America
New York Life Group Insurance Company of NY
© 2021, New York Life Insurance Company, New York, NY. All rights reserved. NEW YORK LIFE and the New York Life box logo are registered trademarks
of New York Life Insurance Company. Life Insurance Company of North America and New York Life Group Insurance Company of NY are subsidiaries of
New York Life Insurance Company.
New York Life Group Benefit Solutions
Facsimile: (800) 642-8553
500385 Rev. 04/2021
YES NO
YES NO
YES NO
DATES OF SERVICE - INCLUDE DATE OF NEXT APPOINTMENT (IF PREVIOUS FORM SUBMITTED TO THIS CARRIER, YOU NEED SHOW ONLY DATES SINCE LAST REPORT).
DATE
REMARKS: WE ARE INTERESTED IN ANY INFORMATION THAT WOULD BE HELPFUL TO YOUR PATIENT FOR EVALUATION OF THIS CLAIM.
IF STILL DISABLED, DATE PATIENT SHOULD BE ABLE TO RETURN TO WORK.
DATE PERFORMED
INPATIENT
OUTPATIENT
THRUIF "YES", CONFINED FROM
HAS PATIENT BEEN HOSPITAL CONFINED?
DATE PATIENT FIRST CONSULTED YOU FOR THIS CONDITION.DATE SYMPTOMS FIRST APPEARED OR ACCIDENT HAPPENED.IS CONDITION DUE TO INJURY OR SICKNESS ARISING OUT OF
PATIENT'S EMPLOYMENT?
COMPLICATIONS
ESTIMATED DATE OF CONFINEMENT
APPROXIMATE DATE PREGNANCY COMMENCED
IF "YES", PLEASE PROVIDE THE FOLLOWING INFORMATION IF APPLICABLE.
YES NO
YES NO
DIAGNOSIS AND CONCURRENT CONDITIONS, INCLUDING ICD OR DSM CODE.
PLEASE LIST ALL BENEFITS YOU ARE RECEIVING OR ELIGIBLE TO RECEIVE UNDER ANY OTHER GROUP INSURANCE, GOVERNMENT PLAN OR AUTOMOBILE MANDATORY NO-FAULT COVERAGE.
PLEASE DESCRIBE YOUR JOB DUTIES IN DETAIL. WHAT PERCENT OF YOUR JOB REQUIRES PHYSICAL LABOR?
BENEFIT DATE BEGANGROSS WEEKLY AMOUNT PAID THRU DATE
TO BE COMPLETED BY ATTENDING PHYSICIAN
IS CONDITION DUE TO PREGNANCY?
DATE OF DELIVERY TYPE OF DELIVERY
PATIENT STILL UNDER YOUR CARE FOR
THIS CONDITION?
HAS PATIENT EVER HAD SAME OR SIMILAR CONDITION?
IF "YES", WHEN AND DESCRIBE
NATURE OF SURGICAL PROCEDURE, IF ANY
PATIENT WAS CONTINUOUSLY TOTALLY DISABLED - (UNABLE TO WORK)
NAME AND ADDRESS OF HOSPITAL
From:
Thru:
PHYSICIAN'S NAME (PRINT)
SIGNATURE
TELEPHONE
ZIP CODESTATE OR PROVINCESTREET ADDRESS
TAX IDENTIFICATION NUMBERDEGREE SOCIAL SECURITY NUMBER
CITY OR TOWN
HAVE YOU HAD THE SAME OR SIMILAR CONDITION IN THE PAST? IF SO, PLEASE DESCRIBE IN DETAIL.
LIST STATES IN WHICH YOU MAY BE LIABLE FOR FILING TAX RETURNSDATE FIRST UNABLE TO WORKDATE OF ACCIDENT OR BEGINNING
OF SICKNESS
DESCRIBE IN YOUR OWN WORDS WHAT IS WRONG WITH YOU (IF ACCIDENT, DESCRIBE
CIRCUMSTANCES AND ADVISE WHETHER IT OCCURRED AT WORK).
DATE YOU PLAN TO RETURN TO WORK
TO BE COMPLETED BY THE CLAIMANT
PLEASE TYPE OR PRINT BE SURE TO ANSWER ALL QUESTIONS - FAILURE TO DO SO MAY DELAY YOUR CLAIM.
USE SEPARATE PIECE OF PAPER TO COMPLETE ANSWERS IF NECESSARY
PLEASE LIST ANY HOSPITALS, CLINICS OR PHYSICIANS THAT TREATED YOU FOR YOUR ILLNESS OR INJURY.
NAME TREATMENT PERIODCOMPLETE ADDRESS
DATE SIGNEDSIGNATURE OF AUTHORIZED REPRESENTATIVE
THIS IS TO CERTIFY THAT THE FACTS AS INDICATED ABOVE ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
Page 2 of 4
PLEASE PROVIDE THE NAME OF YOUR MEDICAL INSURANCE CARRIER
The issuance of this form is not an admission of the existence of any insurance nor does it recognize the validity of any claim and is without
prejudice to the company's legal rights.
500385 Rev. 04/2021
Page 3 of 4
Disclosure Authorization
Claimant's Name:
NOTE: This authorization is designed to comply with the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and
relates to information necessary to administer benefits and services under Employer's employee health and welfare plan(s) ("the
Plan") and statutory and/or private leave of absence or job accommodation programs. "Employer" is defined to mean your
employer, or your family member's employer to the extent benefits, services, or leave are being sought under your family member's
employer's Plan. You are not required to sign the authorization, but if you do not, the Plan, insurers or other providers may not be
able to process your (or your family member's) request for benefits or services under the Plan or statutory and/or private leave of
absence or job accommodation programs.
AUTHORIZATION
I authorize any physician, medical professional or other health care provider, hospital or other medical facility; pharmacy; health
plan; other medically related entity; rehabilitation professional; vocational evaluator; employee assistance plan; insurance company,
reinsurer, health maintenance organization, third party administrator, broker or other insurance service provider, or similar entity;
the Medical Information Bureau; the Association of Life Insurance Companies, which operates the Health Claims Index and the
Disability Income Record System; government organization or agency, including the Social Security Administration; social security
disability advocate or representative; financial institution, accountant or tax preparer; consumer reporting agency; and employer or
group policyholder that has information about my health, prescriptions, financial, earnings or employment history, or other
insurance claims and benefits, to provide access to or copies of this information (whether by written, telephonic or electronic
means) to Life Insurance Company of North America; New York Life Group Insurance Company of NY (Life Insurance Company of
North America and New York Life Group Insurance Company of NY shall be collectively referred to as "Insurance Company"); and
any other individual or entity (including nonaffiliated third parties) that provides services to or insurance benefits on behalf of the
Plan and/or Employer's statutory and/or private leave of absence or job accommodation programs. If I am also covered by Cigna
Health and Life Insurance Company or its affiliates ("Cigna"), I authorize Insurance Company to disclose the health and other
information described above to Cigna to assist me with my health coverage and to provide its services and benefits. This
information will be shared to coordinate benefits and provide other services to you.
Information about my health may relate to any disorder of the immune system including but not limited to HIV and AIDS; use of
drugs or alcohol; and mental and physical history, condition, advice or treatment, but does not include psychotherapy notes or
genetic information.
I agree and understand that any information obtained with this authorization may be used and disclosed for the following
purposes: 1) evaluating and administering coverage, including any claim for benefits, or otherwise providing services related to or
on behalf of the Plan; 2) evaluating and administering services related to Employer's statutory and/or private leave of absence or job
accommodation programs; 3) determining my eligibility for any governmental benefits similar to or that coordinate with benefits
available to me under the Plan and assisting me in applying for such benefits; and 4) evaluating and administering benefits or
services under any other plans sponsored by or offered through Employer such as health management, disease management,
wellness, or employee/member assistance programs.
I understand that the information disclosed under this authorization is subject to redisclosure and may no longer be protected by
HIPAA or other federal regulations governing the privacy of health information, although it may continue to be protected by other
applicable privacy laws and regulations. I further understand that if any information is used for services relating to Employer's leave
of absence or job accommodation programs, that information may be disclosed to Employer at any time. Additionally, I understand
that information may be disclosed to the employee who elected my coverage or submitted a claim for benefits under my coverage,
or requested leave.
This authorization shall be valid for 12 months or the duration of my claim for insurance benefits, whichever is longer. I also
understand that Insurance Company will maintain a copy of this authorization, and that I am entitled to a copy of this authorization
and a photographic or electronic copy of it is as valid as the original.
I understand that I do not have to give this authorization. If I choose not to give the authorization - or if I later revoke - I understand
that the Plan, insurers, or other providers of services or benefits related to the Plan or Employer's statutory and/or private leave of
absence or job accommodation programs who rely on this authorization may not be able to evaluate or administer any request for
benefits, coverage or services and that any request for benefits, coverage or services may be denied as a result. I may revoke this
authorization by sending written notice to the Claim Manager handling the claim.
(Claimant's Signature)
(Date Signed)
(Print Name) (Date of Birth)
I signed on behalf of the claimant as (indicate relationship). If Power of Attorney Designee, Guardian, or
Conservator, please attach a copy of the document granting authority.
© 2020 - 2021, New York Life Insurance Company, New York, NY. All rights reserved. NEW YORK LIFE and the New York Life box logo are registered trademarks of New
York Life Insurance Company. Life Insurance Company of North America and New York Life Group Insurance Company of NY are subsidiaries of New York Life
Insurance Company. Cigna Health and Life Insurance Company is not affiliated with New York Life Insurance Company.
500385 Rev. 04/2021
Page 4 of 4
Minnesota Residents: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a
crime.
District of Columbia Residents: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose
of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny
insurance benefits if false information materially related to a claim was provided by the applicant.
IMPORTANT CLAIM NOTICE
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 a policyholder or claimant for the purpose of defrauding or attempting
to defraud the policyholder or claimant with regard to settlement or award payable from insurance proceeds shall be reported
to the Colorado division of insurance within the department of regulatory agencies.
Oregon Residents: Any person who includes any false or misleading information on an application for an insurance policy,
may be guilty of fraud and may be subject to civil or criminal penalties if intentional and material to the risk assumed.
Virginia Residents: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer,
submits application or files a claim containing a false or deceptive statement may have violated state law.
Rhode Island Residents: 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.
Texas Residents: 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.
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.
Kentucky Residents: Any person who knowingly and with intent to defraud any insurance company or other person files a
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.
Florida Residents: 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 third degree.
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.
Tennessee Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company
for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
California Residents: 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.
Maryland Residents: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or
benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
Kansas Residents: Any person who knowingly and with intent to defraud any insurance company or other person (1) files an
application for insurance or statement of claim containing any materially false information; or (2) conceals for the purpose of
misleading, information concerning any material fact thereto, may be guilty of insurance fraud determined by a court of law.
Louisiana Residents: 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.
Washington Residents: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance
company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
Puerto Rico Residents: Caution: Any person who knowingly and with the intention of defrauding presents false information
in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or
any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction,
shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand
dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be
present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are
present, it may be reduced to a minimum of two (2) years.
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