Free 50106.pdf - Indiana

INSTRUCTIONS FOR SUBMISSION OF A DISABILITY CLAIM
State Form 50106 (R/12-03)

STATE OF INDIANA State Personnel Department, Benefits Division Disability Program

Your Responsibility THE APPLICATION 1 Employee's Claim Statement: Answer each question completely, sign and date. IF ALL QUESTIONS ARE NOT ANSWERED, IT IS NOT COMPLETE AND CANNOT BE PROCESSED. Employee's Authorization For Release of Information: This MUST be signed and dated. Without a signature, your authorization is incomplete and will not be honored by your physician or hospital. Options Statement: Please complete, sign and date this form. Return the Application (the three forms above) to your Agency.

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The Elimination Period for disability benefits is 30 consecutive calendar days. The elimination period for disability benefits from on-the-job injuries resulting from the tortious act of another person is 7 calendar days. The effective date for disability benefits cannot precede the date your application (the 3 forms listed above) is made. Late application WILL result in a loss of benefits. 1 Attending Physician's Statement: Complete the top portion and deliver to your physician. DO NOT TAKE the Employee's Claim Statement, Employee's Authorization for Release of Information, or Option's Statement (your application for benefits) to your physician. This may result in a delay or loss of your benefits. Physician's Responsibility 1 Attending Physician's Statement: After you have completed the top portion, your treating physician completes the remainder. Have your physician return the completed form to you or mail it to JWF Specialty. The Impairment Rating and the Disability Date must be on Attending Physician's Statement.

You are not eligible to receive benefits until the Attending Physician's Statement has been received by JWF Specialty to enable the determination of disability. Agency's Responsibility 1 2 3 4 Complete the Employer's Report of Claim. Confirm current salary, leave balance and last day worked. Document the date the application is received. Agency should send the Employer's Report of Claim and the employee's Application to JWF Specialty immediately. Caution: Do not wait for the Physician's Statement. This may cause a delay in the employee's benefits. You should also file a Report of Injury Claim if this is an on-the-job injury. Forward Attending Physician's Statement to JWF Specialty upon receipt.

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