Get Employee's Statement (with Authorization 127182 Attached) - Ing

Filling out the Employee's Statement (with Authorization 127182 Attached) - ING is an important step in managing your disability claims efficiently. This guide provides straightforward, step-by-step instructions to help you complete the form accurately.

Follow the steps to efficiently complete the form online.

1. Press the ‘Get Form’ button to access the form and open it in the designated editor.
2. In the Group Policyholder Information section, enter your Certificate/Policy Number and Division/Location to identify the insurance policy.
3. Provide your Employee Information, including your Insured Name, Birth Date, Phone Number, Social Security Number (SSN), Gender, and Hand Dominance.
4. Fill in your Address, City, State, Employer Name, and ZIP Code.
5. Indicate the List of Duties, Employment Start Date, Date Last Worked, and Occupation, detailing your job responsibilities.
6. Specify the Cause of Disability and fill out Coverage Effective Date and Date Disability Began.
7. Answer whether employment has been terminated, and if 'Yes,' provide the termination date and reason.
8. Indicate if you have been covered under another group disability income plan in the past two years and provide details if applicable.
9. Complete the section regarding your medical history, including details regarding any physicians, hospitals, or other medical practitioners you have visited.
10. In the Employee Compensation Information section, indicate if you have applied for Workers’ Compensation and any relevant benefits you may be receiving.
11. Read and understand the Employee Certification statement, then sign and date it to verify its accuracy.
12. Complete the Authorization for Release of Information and Health-Related Information sections, giving appropriate permissions and signing where required.
13. After completing all sections, review the document for accuracy and completeness.
14. Save your changes, and download, print, or share the completed form as needed.

Complete your Employee's Statement online to ensure your disability claim is processed smoothly.