HTML version of the form: Claim for Long Term Disability Benefit

Public Service Management Insurance Plan

Industrial Alliance Insurance and Financial Services Inc.
Group Policy No. G68-1400

A claim consists of form 5945 (Parts 1 and 2) and Form 5946 (Parts 1, 2 and 3).

Form 5945

Instructions to Claimant (Form 5945 – attached)

Please complete and sign Part 1 of the attached form. Also complete and sign the authorization at the beginning of Part 2. Then forward the form to the attending physician. Once the entire form has been completed it should be sent directly to Industrial Alliance at the address below, at least two months prior to the date you expect your benefits to become payable, if the claim is approved.

Group Disability Claims
Industrial Alliance Insurance and Financial Services Inc.
522 University Avenue
Toronto, Ontario M5G 1Y7

You are responsible for any costs associated with the completion of the form.

Answer all questions fully. If there is insufficient space for your answers, use separate sheets and attach them to the form.

Please note: Form 5946 must also be completed.

The information you provide in the attached form is collected under the authority of the Treasury Board for the administration of the Public Service Management Insurance Plan. All information provided is strictly confidential.

Part 1: Medical Information. To be completed by the member.

Attach to Part 2

Present illness, injury or disabling condition

Recent illnesses, injuries or disabling conditions (within the last 5 years)

I certify that the above is true and complete and I hereby authorize any physician, medical practitioner, hospital, clinic or other medically related facility, insurance company, the Medical Information Bureau, my employer or other organization, institution or person that has any records or knowledge of me or my health to give to Industrial Alliance Insurance and Financial Services Inc. any such information. I also authorize Industrial Alliance Insurance and Financial Services Inc. to release such documentation or information to any Independent Medical Examiner when Industrial Alliance Insurance and Financial Services Inc. deems it necessary for the purpose of adjudicating or administering this claim. In addition, I consent to a personal investigation. A photostatic or carbon copy of this authorization shall be as valid as the original.

Part 2: Medical Information. Attending physician’s long term disability benefits statement

I hereby authorize the release to Industrial Alliance Insurance and Financial Servics Inc. of any information requested in respect of this claim.

The patient is responsible for the securing of this form and any charge which may be made for its completion.

Attending physician’s statement of disability. To physicians – please note:

This form has been specifically designed with the Physician in mind. By being comprehensive, it will hopefully reduce the Physician’s administrative workload. Please complete the sections relating to your patient and stroke out non-applicable areas. In order to help the claimant, sufficient details of History, Investigation, Findings and Treatment are essential.

This form may be mailed directly to Industrial Alliance Insurance and Financial Services Inc. or given to the patient at the Physician’s discretion. If mailed direct, please address to: Group Disability Claims Department, Industrial Alliance Insurance and Financial Services Inc., 522 University Avenue, Toronto, Ontario M5G 1Y7. Part 1 completed by the patient should be attached.

1. History

  1. When did symptoms first appear or accident happen?
    • Year:
    • Month:
    • Day:
  2. Date total disability commenced?
    • Year:
    • Month:
    • Day:
  3. Has patient ever had same or similar condition?
    • Yes
    • No
    • Unknown
    If "Yes", state when and describe:
  4. Is condition due to a physical or mental impairment arising out of patient’s employment?
    • Yes
    • No
    • Unknown
  5. Names of other treating physicians:

2. Diagnosis

  1. Diagnosis (including any complications)
    • Primary:
    • Secondary (if applicable):
  2. Subjective symptoms:
  3. Objective findings (including results of current x-rays, E.K.G.’s or any other special tests):

3. Treatment

  1. Date of first visit
    • Year:
    • Month:
    • Day:
  2. Date of latest visit
    • Year:
    • Month:
    • Day:
  3. Frequency
    • Weekly
    • Monthly
    • Other (specify):
  4. Is patient following recommended treatment program?
    • Yes
    • No

4. Type of Treatment

  1. Describe therapy and projected duration of treatment program:
  2. Date and description of surgery (if applicable)
    • Year:
    • Month:
    • Day:

5. Physical Impairment

Is patient:

If ambulatory and/or house confined, please complete the section below:

Remarks:

6. Mental Impairment

Remarks:

7. Effect of Physical or Mental Impairment on Duties of Job

Please explain the extent to which the patient’s physical or mental impairment affects his or her capacity to:

  1. perform his or her regular duties
  2. perform any other occupation compatible with the patient’s condition
  3. if physical impairment involved, what are the effects on:
    1. Patient’s regular Occupation:
    2. Any other Occupation:

8. Prognosis

  1. Does disability prevent patient from performing?
    • Regular Occupation
      • Yes
      • No
    • Any other Occupation
      • Yes
      • No
  2. If "Yes", please indicate when you do expect patient will recover sufficiently to perform duties of
    • Regular Occupation
      • 1 - 3 months
      • 3 - 6 months
      • Other:
      • Never
    • Any other Occupation
      • 1 - 3 months
      • 3 - 6 months
      • Other:
      • Never
  3. If "No", please indicate date patient was able to perform duties of
    • Regular Occupation
      • Year:
      • Month:
      • Day:
    • Any other Occupation
      • Year:
      • Month:
      • Day:

9. Cardiac (if applicable)

  1. Functional capacity
    • Class 1 (no limitation)
    • Class 2 (slight limitation)
    • Class 3 (marked limitation)
    • Class 4 (complete limitation
  2. Blood Presure (latest visit):

10. Visual Impairment (if applicable)

  1. What was vision at latest observation
    1. With glasses
      • O.D.:
      • O.S.:
    2. Without glasses
      • O.D.:
      • O.S.:
  2. Vision can be restored in whole or in part by
    • O.D.
      • Lenses
      • Treatment
      • Operation
      • Not restorable
    • O.S.
      • Lenses
      • Treatment
      • Operation
      • Not restorable

11. Rehabilitation

  1. Is patient a suitable candidate for trial employment?
    • For regular Occupation
      • Yes
      • No
    • For any other Occupation
      • Yes
      • No
  2. If "Yes", when could trial employment comment?
    • Regular Occupation
      • Full-time
        • Year:
        • Month:
        • Day:
      • Party-time
        • Year:
        • Month:
        • Day:
    • Any other Occupation
      • Full-time
        • Year:
        • Month:
        • Day:
      • Party-time
        • Year:
        • Month:
        • Day:
  3. Would vocational counselling an/or retraining be recommended?
    • Yes
    • No

Remarks:

Form 5946

Instructions to Claimant (Form 5946 – attached)

Please complete and sign Part 1 of the attached form. Then forward the form to your personnel officer at least two months prior to the date you expect your benefits to become payable, if the claim is approved.

Answer all questions fully. If there is insufficient space for your answers, use separate sheets and attach them to the form.

Please note: Form 5945 must also be completed.

Instructions to Personnel Officer (Form 5946 – attached)

Please review Part 1 of the attached form to make certain that it has been fully completed. Please complete and sign Part 2. Then forward the form to Superannuation Directorate, Public Works and Government Services Canada.

The information you provide in the attached form is collected under the authority of the Treasury Board for the administration of the Public Service Management Insurance Plan. All information provided is strictly confidential.

For dept. Use

Part 1: To be Completed by the Member (Claimant)

Please note that the LTD benefit is subject to income tax. For Quebec residents, it is required that Quebec Income Tax be deducted at source. For Federal Income Tax, deduction at source is not necessary, but can be arranged if desired.

I certify that the above is true and complete and I hereby authorize any physician, medical practitioner, hospital, clinic or other medically related facility, insurance company, the Medical Information Bureau, my employer or other organization, institution or person that has any records or knowledge of me or my health to give to Industrial Alliance Insurance and Financial Services Inc. any such information. I also authorize Industrial Alliance Insurance and Financial Services Inc. to release such documentation or information to any Independent Medical Examiner when Industrial Alliance Insurance and Financial Services Inc. deems it necessary for the purpose of adjudicating or administering this claim. In addition, I consent to a personal investigation. A photostatic or carbon copy of this authorization shall be as valid as the original.

Part 2: To be Completed by the Personnel Officer

Please attach a detailed job description and forward to Superannuation Directorate of Public Works and Government Services Canada.

Part 3: To be Completed by the Member’s Supervisor

In what way was the Member’s performance on the job affected by his/her disability?

Were the Member’s duties modified? e.g.: Shorter hours, other jobs, etc.

Part 4: To be Completed by the Superannuation Directorate

Other coverages

We certify that Long Term Disability Insurance was in force on the last day of active employment. We have confirmed that the adjusted annual rate shown by the personnel officer is correct.

Superannuation Directorate, please forward this form with job description to Industrial Alliance Insurance and Financial Services Inc..

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