Sample LTD application

• Author: Scott M. Riemer/Jennifer L. Hess
• Pages: 211-214

A - 19 3 Appendix: Sample Documents Form 3

FORM 3 SAMPLE LTD APPLICATION

VIA FAX AND MAIL

INSURANCE COMPANY

Re: CLIENT

DOB: 02/06/19

Policy No.: XXXXX

Dear Sir or Madam:

We represent CLIENT in his disability claim. Proper authorizations are

  

the following:

1. INSURANCE COMPANY Part A, Insured’s Statement for Disability

 

for the most complete answers;

2. INSURANCE COMPANY Part B, Insured’s Statement of Occupational

Description;

3. INSURANCE COMPANY Part C, Authorization to Obtain and Disclose

Information;

4. Authorization for Release of Personal Health-Related Information HIPAA

Privacy Rule and Psychotherapy Notes executed by CLIENT dated

April 12, 2020;

5. INSURANCE COMPANY Part D, Attending Physician’s Statement of



April 17, 2020 as well as Attending Physician’s Statement completed for

UNUM dated April 12, 2020;

6. Job Description, Resume, Pay stub, Health Care Provider List, Medica-

tion List; and the following Medical Records and Reports in support of

CLIENT’s disability claim:

• Neuropsychological Evaluation Report completed by Dr. dated March

15, 2020;

• Functional Capacity Evaluation Summary Report dated February 21

and 22, 2020 completed by ___________;