Get 2012 Standard Ltd Claim Form.pdf - Florida Atlantic University

This guide provides clear instructions on completing the 2012 Standard LTD Claim Form from Florida Atlantic University. Whether you are new to filing such claims or need a refresher, this guide will walk you through each section of the form to ensure accurate and efficient completion.

Follow the steps to successfully complete your claim form.

1. Press the ‘Get Form’ button to access the claim form document and open it for editing.
2. Begin with the Claimant section. Fill out your full name, Social Security number, address, phone number, and birthdate. Indicate your gender and record the birthdate of your youngest child if applicable.
3. Complete the Employment section. Provide information about your employer, job title, and a brief description of your duties. Answer whether your disability is work-related, and indicate if you have filed a Workers’ Compensation claim.
4. In the Sickness section, list all illnesses contributing to your disability, including their dates of onset. Describe the symptoms and any previous related conditions.
5. If applicable, fill out the Pregnancy section. Provide your expected delivery and return to work dates, along with any foreseeable complications.
6. Provide a list of all physicians consulted in the Attending Physician section. Include their names, specialties, and contact information.
7. Fill out the Hospital section if you were hospitalized, including the hospital name, dates of stay, and reasons for hospitalization.
8. In the History section, list any previous ailments treated over the last five years. Ensure to include the physician’s name and address.
9. Next, document any Deductible Income or Benefits you are receiving. This includes Social Security and Workers’ Compensation. Specify if you have applied or are receiving any other benefits.
10. In the Vocational section, detail your education and work experience. Complete all areas and ensure that your job history is accurate and up-to-date.
11. Finally, review the Acknowledgement section. Sign and date the form, confirming that all information is correct to the best of your knowledge.
12. Once completed, you may either save or print the form for your records and submit it as instructed.

Begin filling out your claim form online now to ensure a timely submission!