HTML version of the form: Claim for Disability Insurance Employer's Statement Policy No. 12500-G

PROTECTED once completed

Part 1 asks for information on the employee’s employment and coverage status. This part must be completed by the Human Resources Officer or Compensation Advisor.

Part 2 asks for information on the employee’s specific duties. This part must be completed by the employee’s immediate supervisor or manager. Please attach a current work description.

Sun Life Assurance Company of Canada (referred to in this form as the “Insurer”) must receive this form, the Employee’s Statement and the Attending Physician’s Statement to review this claim. Please complete this form in its entirety and submit it by fax ideally at least 8 weeks before the end of the elimination period but no later than 90 days after the end of the elimination period in order to avoid delays. If a claim form is submitted later than 90 days after the end of the elimination period, the employee may not be entitled to Disability Insurance Plan benefits if the delay impedes the Insurer’s ability to assess the claim. See submission instructions at the end of the form.

To avoid overpayment, you must advise the Insurer immediately when the employee returns to work.

Part 1: Employment and Insurance Information

(to be completed by the Human Resources Officer or Compensation Advisor)

Employer Information

• Department or Organization Name:
• Address (Street No. and Name, Suite No.):
• City:
• Province:
• Postal Code:
• Telephone No.:
• Pay Office:
• Departmental Alpha Code:
• Paylist:
• Bargaining Unit Designator (BUD) No.:
• Classification, Group and Level.:

Employee Information

• Name (First and Last) (Quebec residents: Use maiden name, if applicable.):
  • Male:
  • Female:
• Date of Birth (dd/mm/yy):
• Proof of age required if aged 60 or over:
  • Yes:
  • No:
• Address (Street No. and Name, Apartment or Suite No.):
• City:
• Province:
• Postal Code:
• Home Telephone No.:
• Alternate Telephone No.
• Pension No.:
• Certificate No. - CG-:

Coverage Information

• Last date of entry into the federal public service: Day / Month / Year:
• Date Disability Insurance coverage became effective: Day / Month / Year:
• Has this insurance coverage ever been terminated?
  • No:
  • Yes:
    • If yes, give date and reason as well as date of reinstatement.:
• Month and year last Disability Insurance premium was deducted:
  • Month:
  • Year:

Employment Information

1. Employment status when last hired (Check one):

   	Full-time	Part-time
   Indeterminate
   Term of 6 months or less
   Term of more than 6 months
   Seasonal
   Other (specify)

2. Location of employment:

   • Office:
   • Home:
   • Elsewhere (Explain below):
3. Last day actively at work prior to disability? Day / Month / Year:
4. If the employee remains actively at work but has reduced hours due to illness, please indicate the effective date of the reduced work schedule. Day / Month / Year:
5. What was the employee’s job title on the last day worked?
6. From what date has the employee been appointed this position? (Attach current job description.) Day / Month / Year:
7. 1. How many hours was the employee assigned to work per week based on his or her substantive position?
   2. On what date were these assigned hours authorized? Day / Month / Year:
   3. If the employee is a part-time employee, what are the equivalent full-time hours?
   4. If the employee is a part-time employee, what is the equivalent full-time salary? $:
8. If the employee changed positions or assignments during the 12 months immediately before the last day worked, list the previous positions or assignments. Please also give the reasons for the changes and the effective dates of the changes.:
9. Did the employee leave work for medical reasons?
   • No:
   • Yes:
10. Was the employee working modified duties prior to ceasing full-time work? If so, please describe the modifications.:
11. If the employee is absent for any reason other than illness or disability (e.g. maternity leave), please give details.:
12. Was the employee on leave without pay?
    • No:
    • Yes:
      • If yes, from what date? Day / Month / Year:
13. 1. Has the employee been permanently struck off strength?
       • No:
       • Yes:
         • If yes, from what date? Day / Month / Year:
    2. Give details:
14. Has the employee returned to work?
    • No:
    • Yes:
      • If yes, on what date? Day / Month / Year:
15. Indicate the anticipated date of return to work. Day / Month / Year:
16. Is the employee’s substantive position still available?
    • No:
      • If no, give reason:
    • Yes:
17. To your knowledge, is the employee now working elsewhere?
    • No:
    • Yes:
      • If yes, give details:
18. Please attach a copy of the employee’s leave records, along with an explanation of the codes.:

Earnings and benefit information

For questions that do not apply, please insert "N/A" in the blank space.

1. Give details of the employee’s insured salary and allowances as of the last day of the elimination period. (Use the proportional rate for employees working less than full-time hours.)

   • Authorized Rate of Pay:
   • Rate - $ per:
   • Yearly $:
   • Insured Allowance(s) - specify type(s):
   • Rate - $ per:
   • Total $:
2. What is the total adjusted annual salary? (If total salary is not a multiple of $250, round it up to the next multiple of $250.) $:
3. What are the total personal federal income tax exemptions from the last TD1? (For Quebec residents, use the last TPD1.) $:
4. For Quebec residents, what are the total personal provincial income tax exemptions from the last MR19? $:
5. 1. Does the employee have unused sick leave on the last day actively at work?(Include credits earned during the elimination period.):
      • No:
      • Yes:
        • If yes, how many days?
   2. Has the employee been granted advanced sick leave?
      • No:
      • Yes:
        • If yes, how many days?
6. What was/is the last date of paid sick leave? (5a + 5b) Day / Month / Year:
7. If the employee was/is not allowed to use all available sick leave credits, give the date the credits would have ended and the reason(s) the employee was/is not allowed to use them. Day / Month / Year:
8. Was any other type of paid leave granted?
   • No:
   • Yes:
     • If yes, give date and details. Day / Month / Year:
9. On what date will the paid leave end? Day / Month / Year:

Workers’ Compensation

1. If the employee’s illness or injury is work related, has he or she applied for Workers’ Compensation benefits?
   • No:
   • Yes:
     • If yes, please continue.
       • What is the claim number?:
       • How much is the benefit per month?:
2. Has the employee received a permanent disability award?
   • No:
   • Yes:
     • If yes, when did he or she receive it? Day / Month / Year:

   Was it a monthly benefit?

   • No:
   • Yes:
     • If yes, what was the amount? $:

   Was it a lump-sum settlement?

   • No:
   • Yes:
     • If yes, what was the amount? $:
3. If the employee’s claim has been denied or terminated, has he or she appealed the decision?
   • No:
   • Yes:
     • If yes, when was it appealed? Day / Month / Year:

   Please indicate the stage of the employee’s appeal (if known).

   • Oral
   • Board of review
   • Medical panel
   • Medical review
   • Other

Declaration for Part 1

The information given in Part 1 of this form is true and complete according to our records.

• Name of Human Resources Officer or Compensation Advisor (please print):
• Title:
• Address:
• Telephone No.:
• Email Address:
• Fax No.:
• Signature:
• Date (Day/Month/Year):

Part 2: Information About Employee’s Disability and Job

(to be completed and signed by employee’s immediate supervisor or manager)

Information About the Disability and Rehabilitation

Attach extra sheets, if necessary.

Many employees who are disabled could be working productively if they were provided with help and encouragement toward this goal. When the Insurer, Sun Life Assurance Company of Canada, feels that the employee is a suitable candidate for vocational rehabilitation, a Sun Life Health Management Consultant will contact the employing department to partner in identifying opportunities for the employee’s return to work. The Disability Insurance Plan Board of Management and the Treasury Board of Canada Secretariat, on behalf of the policyholder, strongly support vocational rehabilitation and the efforts of departments, agencies and Sun Life to return employees to suitable and productive work.

Please identify the department or agency official Sun Life should contact if the employee is considered capable of vocational rehabilitation.

• Name:
• Title:
• Address:
• Telephone No.:
• Email Address:
• Fax No.:

1. Please attach the work description.:
2. When did the employee’s illness or injury first appear to affect his or her work? Day / Month / Year:
3. From your observations, did the employee’s ability to perform his/her job change?
   • No:
   • Yes:
     • If yes, give details.:
4. Were any changes made in the employee’s job as a result of the illness or injury?
   • No:
   • Yes:
     • If yes, give details.:
5. If the employee could return to work on a reduced schedule or with a change in duties, would a position be available?
   • No:
   • Yes:
     • If yes, give details.:

Work Environment and Job Activities

1. Does the employee’s job require work in any of the following conditions?
   • Outside:
     • No:
     • Yes:
       • If yes, what percentage of time?
   • In extremes of cold or heat:
     • No:
     • Yes:
       • If yes, what percentage of time?
   • In a damp or humid environment:
     • No:
     • Yes:
       • If yes, what percentage of time?
   • In a noisy environment:
     • No:
     • Yes:
       • If yes, what percentage of time?
   • In a dusty or unventilated environment:
     • No:
     • Yes:
       • If yes, what percentage of time?
   • Around toxic fumes:
     • No:
     • Yes:
       • If yes, what percentage of time?
2. Does the employee’s job involve handling chemicals?
   • No:
   • Yes:
     • If yes, please list the chemicals:

3. During the employee’s normal routine, what percentage of time does the job require the employee to lift or carry the following weights?

   	0	1 to 25%	26 to 50%	51 to 75%	76 to 100%
   More than 50 lbs / 22.7 kg
   More than 20 lbs / 9.1 kg
   More than 10 lbs / 4.5 kg

4. During the employee’s normal routine, what percentage of time does the job involve the following activities?

   	0	1 to 25%	26 to 50%	51 to 75%	76 to 100%
   Walking
   Climbing
   Driving:
   Daytime
   Nighttime
   Reaching:
   Above shoulder height
   At shoulder height
   Below shoulder height
   Bending or crouching
   Kneeling or crawling

5. How much time is the employee required to maintain the following positions or activities before changing position or activity?

   	0 to 30 minutes	31 to 60 minutes	61 to 90 minutes	more than 90 minutes
   Sitting at one time
   Standing at one time
   Driving at one time

6. During the average day, how many hours does the employee spend in the following positions or activities?

   	0 to 2 hours	3 to 4 hours	5 to 6 hours	7 to 8 hours
   Sitting
   Standing
   Driving

7. Please list any machine, tool or other equipment that the employee uses on the job and provide either the number of times per day that he or she uses it or the percentage of time that he or she spends using it, whichever is most applicable.
   • Machine, tool or other equipment:
   • No. of times per day / Percentage of time:
8. Cognitive/non-physical aspects of the job:
   • Does the employee have to answer complaints?
     • No:
     • Yes:
   • Is the employee primarily evaluated on production?
     • No:
     • Yes:
   • Does the employee work closely with co-workers?
     • No:
     • Yes:
   • Is the employee responsible for performance objectives and decision making within his or her particular department?
     • No:
     • Yes:
   • Number of people this employee supervises:
   • What percentage of the employee’s time is spent on the following activities?
     • Talking %:
     • Writing %:
     • Supervising other people %:
   • Please list any other relevant aspects of the job that may be considered stressful.:

Additional Remarks

Please provide any additional information that is relevant to this claim but has not been previously provided.

Declaration for Part 2

To the best of my knowledge, the information given in Part 2 of this form is true and complete.

• Name of Immediate Supervisor (please print):
• Title:
• Address:
• Telephone No.:
• Email Address:
• Fax No.:
• Signature:
• Date:

To ensure prompt processing, please fax this form, along with any other information in support of the plan employee’s claim, to the number provided for the Sun Life Assurance Company of Canada Group Disability Management Office that manages your claims.

If you are unable to fax this information, you may mail it to the appropriate address. You do not need to mail information that you fax. Please retain the original copy for your records.

Fax: 1-866-639-7849

Montreal Group Disability Management Office
Federal Government Disability Insurance Plan
Sun Life Assurance Company of Canada
P.O. Box 12500 Station CV
Montréal, Quebec H3C 5T6

TBS/SCT 330-303E (10/2014)