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