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