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