Short-Term Disability Claim Notification Form

Remember to print this form as a copy is not available.

Employment Information

Employer Name

Group Policy Number

Address

Telephone Number
 
 

Personal Information

Name

 Social Security Number
Address Birthdate
Number Where You Can Be Reached      
Gender Marital Status
Job Title
Job Duties
 

Injury/Illness Information
Date of Disability
(first day missed work)
Nature of the injury or illness
 

Physician Information
Physician
Physician's office phone number
Attending physician's address
 
When would be a good time for a Mutual of Omaha Disability Claims analyst to call you back?
(Mutual of Omaha's regular business hours are 8:00 AM to 4:00 PM CST, Monday through Friday.)

 

Please note: Submission of this form does not guarantee benefits. A determination of benefits will be made based on eligibility and plan provisions. We may require additional information.


Close Window