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