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Employees complete Section 1, including personal details, disability cause, work dates, and a required authorization for release of information, consent, and reimbursement agreement. Employers complete Section 2, confirming employment details, insurance effective dates, wage and compensation fields, eligibility answers, and premium contribution information. 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Have your physician complete Section 3. Also complete and sign the Authorization for Release of Information, Communication Consent, and Reimbursement Agreement forms. Submit the forms to us at the address or fax number listed to the right. Your cooperation will facilitate payments promptly when they are due.  \nAny person who knowingly, and with intent to defraud any insurance company, files a statement of claim containing any false, incomplete or misleading information may be subject to criminal penalties.  \nThe Standard  \nDisability Claims Service Center  \nP. O. Box 2717  \nPortland, OR 97208-9830 Phone: 800-232-0113 Fax: 800-850-0017  \n[Email:](Email: AL-Claims@standard.com)[ AL-Claims@standard.com](Email: AL-Claims@standard.com)  \nNotice to customers regarding telephone service observance — To ensure our customers receive quality service, all of our phone calls are recorded. These calls, between our customers and employees, are evaluated by supervisors. This is to assure that prompt, consistent assistance, and accurate information is delivered in a professional manner. We have been properly licensed by the Georgia Public Service Commission to use such observing equipment.  \nSection 1: To be completed by the employee  \n\n| Last name |  | First name |  |  |  | M. I. |  | Gender\u003Cbr> Male  Female |  | Birth date (MMDDYYYY)\u003Cbr>\u003Cbr>|  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Social Security no. | Employee street address |  |  |  | City |  |  |  |  | State | ZIP code |  |\n| Primary phone no. | Alternate phone no. |  | Fax no. |  |  |  | Email address |  |  |  |  |  |\n| Marital status\u003Cbr> Single  Married  Separated  Divorced  Widowed |  |  |  | Employer name |  |  |  |  |  |  |  |  |\n| Disability due to  Illness  Injury | Date you last worked due to your disability \u003Cbr>|  |  | Date you returned to work \u003Cbr>|  |  |  |  | If not yet returned, date you expect to return\u003Cbr>|  |  |  |\n| If disability due to injury, what type?  Auto  Workers’ Compensation  Home  Other:   Please provide complete details to accident, date and time. Attach a separate sheet if necessary. |  |  |  |  |  |  |  |  |  |  |  |  |\n| I authorize the release to or by one or more of the following, herein referred to as ‘Insurance Company’: Standard Insurance Company, The Standard Life Insurance Company of New York, any medical or insurance information required to process my claim. I understand that any information obtained pursuant to this authorization will be used only to evaluate my claim and may be transferred to any organization or person employed by or representing the Insurance Company to assist with this purpose. This authorization is valid for the duration of my claim. I understand I have a right to request and receive a copy of this authorization. A photocopy of this authorization is as valid as the original.\u003Cbr>The above statements are true and complete to the best of my knowledge and belief. Your signature is required for benefit consideration. |  |  |  |  |  |  |  |  |  |  |  |  |\n| For New York residents, the following statement applies: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation. |  |  |  |  |  |  |  |  |  |  |  |  |\n| Employee signature\u003Cbr>X |  |  |  |  |  |  |  |  |  | Date (MMDDYYYY)\u003Cbr>\u003Cbr>|  |  |\n\nSection 2: To be completed by the employer  \n\n| Group policy no. | Date employed (MMDDYYYY","cbCaibMTpGdGEOGs","https://ap.wps.com/l/cbCaibMTpGdGEOGs","pdf",339076,"English","# Section 1: To be completed by the employee\n## Required employee fields and authorization\n# Section 2: To be completed by the employer\n## Employer eligibility, wages, and premium contributions","[{\"question\":\"Who completes Section 1 and what does it require?\",\"answer\":\"Section 1 is completed by the employee. It includes personal information, disability details, work dates, and required authorization and signature for benefit consideration.\"},{\"question\":\"What information must the employer provide in Section 2?\",\"answer\":\"Section 2 is completed by the employer. It includes group policy details, employment dates, effective insurance dates, occupation, weekly benefits, wage/compensation, and eligibility questions about employment-related injury or illness.\"},{\"question\":\"Why is there an authorization for release of information in the form?\",\"answer\":\"The form authorizes release to or by named insurance organizations and specifies that information is used only to evaluate the claim and may be transferred to organizations assisting processing. The authorization is valid for the duration of the claim.\"}]","Short Term Disability Claim Form - Form Submission | PDF",1789800007]