CAF001DI SHORT TERM DISABILITY CLAIM FORM PART B: EMPLOYER’S STATEMENT: (To be completed by your Benefits Department unless self-employed) EMPLOYEE’S NAME: EMPLOYEE ID NUMBER DATE OF BIRTH DATE OF HIRE OCCUPATION AT TIME LAST WORKED: __________________________ EMPLOYEE’S JOB TITLE DUTIES: (Please circle selection in each category) LIFTING LESS THAN 15LBS. 15 TO 44 OVER 45 STOOPING/BENDING NONE SELDOM FREQUENT REPETITIVE NONE SELDOM FREQUENT CRAWLING/CLIMBING/KNEELING NONE SELDOM FREQUENT REACHING/PULLING/PUSHING NONE SELDOM FREQUENT MANAGEMENT DUTIES NONE SELDOM FREQUENT SITTING (NUMBER OF HOURS EACH DAY) ____________ STANDING/WALKING (HOURS EACH DAY) _____________ DATE EMPLOYEE WAS ACTUALLY LAST PRESENT AT WORK? WORK SCHEDULE AT TIME LAST WORKED: DAYS/WEEK: HOURS/DAY: DATES EMPLOYEE DID NOT WORK AT ALL: FROM: THROUGH: DATES EMPLOYEE WORKED LESS THAN FULL-TIME HOURS: FROM: THROUGH: DATE THE EMPLOYEE RETURNED TO FULL- TIME WORK OR LIGHT DUTY/PART-TIME: IF THE EMPLOYEE HAS NOT RETURNED, IS LIGHT DUTY AVAILABLE? IF THE EMPLOYEE RETURNED TO WORK LIGHT DUTY/ PART TIME: PLEASE PROVIDE HOURS WORKED AND EARNINGS: DID THE CLAIM RESULT FROM JOB ACTIVITY? HAS A WORKER'S COMPENSATION CLAIM BEEN FILED? NO/ YES STATUS � APPROVED � PENDING � DENIED IF DENIED, HAS AN APPEAL BEEN FILED? Y/ N HAS THE EMPLOYEE RECEIVED ANY OTHER INCOME AS A RESULT OF DISABILITY? � NO � YES SALARY CONTINUANCE, SICK PAY OR VACATION WEEKLY BENEFIT: __________ DATE CEASED ____________ IS ANY PORTION OF THE EMPLOYEE'S POLICY PAID FOR BY THE EMPLOYER? � NO � YES IS THE EMPLOYEE’S POLICY PAID FOR WITH PRE-TAX DOLLARS (SECTION 125)? � NO � YES WHAT ARE THE EMPLOYEE’S BASIC MONTHLY EARNINGS? IF WORKING THE EMPLOYEE IS WORKING LIGHT DUTY OR PART- TIME, PLEASE PROVIDE EARNINGS AND HOURS WORKED: AUTHORIZED EMPLOYER'S SIGNATURE EMPLOYER’S COMPANY NAME: TELEPHONE NUMBER: FAX NUMBER: ADDRESS: NAME AND TITLE OF PERSON COMPLETING THIS FORM: SIGNATURE OF AUTHORIZED EMPLOYER REPRESENTATIVE: DATE: CONTINENTAL AMERICAN INSURANCE COMPANY Post Office Box 84075 * Columbus, GA. 31993 Phone (800) 433-3036 * Fax (866) 849-2970 * IF SELF-EMPLOYED, PLEASE SUBMIT 1099 FORM FOR VERIFICATION * IF EMPLOYEE IS RECEIVING ANY OTHER INCOME, PLEASE SPECIFY TYPE AND AMOUNT OF INCOME