Get 1199 Disability Forms 2020-2025

1199SEIU National Benefit Fund 330 West 42nd Street New York NY 10036-6977 Tel 646 473-9200 www. 1199SEIUBenefits. org Notice and Proof of Claim for Disability Benefits Healthcare Provider must Complete Part B on Reverse Side Employer must Complete Part C Attachment Member Read the following instructions carefully 1. Use this form only if you become sick or disabled while employed or if you become sick or disabled within four 4 weeks after termination of employment. Pursuant to 45 CFR 164. 512 these legally required medical reports are exempt from HIPAA s restrictions on disclosure of health information. Attention Payroll Department The above member is the process of filing a claim for Disability Benefits with the 1199SEIU National Benefit Fund. Since you are the present employer you are required by the Union Contract and the Trustees of the Fund to promptly complete the Employer s Statement below and return the completed form to the employee. 1199SEIU National Benefit Fund 330 West 42nd Street New York NY 10036-6977 Tel 646 473-9200 www. 1199SEIUBenefits. org Notice and Proof of Claim for Disability Benefits Healthcare Provider must Complete Part B on Reverse Side Employer must Complete Part C Attachment Member Read the following instructions carefully 1. Use this form only if you become sick or disabled while employed or if you become sick or disabled within four 4 weeks after termination of employment. Use green Claim Form DB-300 if you become sick or disabled after having been unemployed more than four 4 weeks. 2. You must complete all items of Part A the Member s Statement. Be accurate. Check all dates. 3. Be sure to date and sign your claim see item 12. If you cannot sign this claim form your representative may sign on your behalf* In that event the representative s relationship to you and address should be noted under the signature. 4. Do not mail this claim unless your healthcare provider completes and signs Part B and you complete the Member s section at the top of Part C and mail to your employer. 5. Your completed claim and Employer s Statement should be mailed within thirty 30 days after you become sick or disabled to the 1199SEIU National Benefit Fund* 6. Make a copy of this completed form for your records before you submit. Part A Member s Statement Please Print in Black or Blue Ink 1. Member s Full Name 2. Member s ID 3. Address City / 4. Date of Birth Month Day Year Answer All Questions Telephone State Zip Code Check Box if New Address 5. Married check one Yes No My disability is if injury also state how when and where it occurred a* Are you taking legal action Yes No If yes Lawyer s Full Name Lawyer s Address a* I worked on that day I became disabled on Yes No b. I have since worked for wages or profit Yes No If Yes give dates Give name of last employer. If more than one employer during last eight 8 weeks name all employers. Employer Business Name Business Address Business Telephone No* Dates of Employment From Through Mo.