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