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