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