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