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