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