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