500469 Rev. 04/2021 PLEASE COMPLETE IN FULL TO BE COMPLETED BY THE EMPLOYER NAME OF EMPLOYEE ( Last, First, M.I.) SOCIAL SECURITY NO. ACCOUNT NUMBER DATE HIRED EFFECTIVE DATE OF EMPLOYEES LTD COVERAGE WITH NEW YORK LIFE GROUP BENEFIT SOLUTIONS WAS EMPLOYEES LTD INSURANCE ISSUED ON THE BASIS OF A STATEMENT OF PHYSICAL CONDITION? IF YES, ATTACH COPY BASIC EARNINGS Wk. Mo. DATE OF LAST CHANGE IN EARNINGS LAST DATE(S) WORKED # Hrs. Supervisory DATE(S) RETURNED TO WORK PLEASE CHECK THE APPROPRIATE BLOCKS: Exempt Management Union Local # Salaried Full Time Part Time Non-Supervisory Non-Exempt Non-Management Non-Union Hourly Hrs/wk: HAS EMPLOYEE BEEN TERMINATED? NAME AND ADDRESS OF WC CARRIER AND WC CLAIM NUMBER IS EMPLOYEE ELIGIBLE FOR GROUP PENSION $ % IF YES, MONTHLY AMOUNT EMPLOYEE % CONTRIBUTION To Pension $ IF YES, DATE REASON PERCENTAGE OF EMPLOYEE CONTRIBUTION TOWARD DISABILITY PREMIUM(see Internal Revenue Code Section 105(a) and Regulations thereunder) PREMIUM PAID THRU DATE % WAS SALARY CONTINUED BEYOND LAST DAY WORKED? HAS EMPLOYEE RECEIVED SHORT TERM BENEFITS? HAS EMPLOYEE RECEIVED STATE DISABILITY BENEFITS? HAS EMPLOYEE FILED A WORKERS COMPENSATION CLAIM? DISABILITY PENSION IF YES, WEEKLY AMOUNT PAID THRU EFFECTIVE IF YES, WEEKLY AMOUNT FROM IF YES, WEEKLY AMOUNT IS THIS A FROM $ EARLY RETIREMENT IF YES, WEEKLY AMOUNT $ $ THRU approved or pending? NORMAL RETIREMENT If yes, THRU FROM THRU LIST ANY OTHER SOURCE OF INCOME TO WHICH THE EMPLOYEE IS ENTITLED AS A RESULT OF THIS DISABILITY OCCUPATION (ATTACH JOB DESCRIPTION IF AVAILABLE: IF NOT, DESCRIBE JOB DUTIES BELOW) Was employees job primarily sedentary or did it involve considerable physical activity? AS CLOSELY AS POSSIBLE, PLEASE ESTIMATE THE PERCENT OF TIME SPENT (TOTAL PERCENTAGE MUST EQUAL 100%): Sitting Standing Walking Climbing Stooping Bending Pushing Lifting Carrying* *If job duties require lifting or carrying, indicate average and maximum weights handled. REMARKS EMPLOYER DIVISION ADDRESS TELEPHONE NUMBER AUTHORIZED REPRESENTATIVE DATE PRINT: SIGNATURE: HAVE ALL PAGES OF THE FORM BEEN COMPLETED IN FULL? ATTACH THE ATTENDING PHYSICIANS STATEMENT OF DISABILITY AND ANY OTHER DOCUMENTATION. Page 2 of 4 EMPLOYEES CONTRIBUTIONS WERE MADE ON: No Yes No Yes No Yes No Yes No Yes No Yes No Yes Post-tax Basis Pre-tax or