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