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