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