Benefit Percentage Eligibility Class Pre- Existing Condition Census Evidence of Insurability Basic Compensation Amendment Pending Claim Partial Disability Effective Date Benefit Period Recurrent Disability Self- Billed Date of Disability Policy Contributory Total Disability Short Term Disability (STD Eligibility Period Elimination Period Prior Plan Proof of Loss Minimum Benefit Grace Period Offset Enrollment Form Non- Contributory Premium Eligibility Date Maximum Benefit Free! Waiver of Premium Late Applicant Exclusion Maximum Benefit Period List Billed Open- Enrollment Period Attending Physician’s Statement Waiting Period Benefit Percentage Eligibility Class Pre- Existing Condition Census Evidence of Insurability Basic Compensation Amendment Pending Claim Partial Disability Effective Date Benefit Period Recurrent Disability Self- Billed Date of Disability Policy Contributory Total Disability Short Term Disability (STD Eligibility Period Elimination Period Prior Plan Proof of Loss Minimum Benefit Grace Period Offset Enrollment Form Non- Contributory Premium Eligibility Date Maximum Benefit Free! Waiver of Premium Late Applicant Exclusion Maximum Benefit Period List Billed Open- Enrollment Period Attending Physician’s Statement Waiting Period
(Print)
Benefit Percentage
Eligibility
Class
Pre-Existing Condition
Census
Evidence of Insurability
Basic Compensation
Amendment
Pending Claim
Partial Disability
Effective Date
Benefit Period
Recurrent Disability
Self-Billed
Date of Disability
Policy
Contributory
Total Disability
Short Term Disability (STD
Eligibility Period
Elimination Period
Prior Plan
Proof of Loss
Minimum Benefit
Grace Period
Offset
Enrollment Form
Non-Contributory
Premium
Eligibility Date
Maximum Benefit
Free!
Waiver of Premium
Late Applicant
Exclusion
Maximum Benefit Period
List Billed
Open-Enrollment Period
Attending Physician’s Statement
Waiting Period
