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Initial Claimant's Statement for Income Replacement/Waiver of Premium Benefits

Last updated: May 13, 2025
Initial Claimant's Statement for Income Replacement/Waiver of Premium Benefits

This document is an initial claimant's statement used for requesting income replacement or a waiver of premium benefits due to a disabling condition. It includes fields for personal details, employment information, medical history, and occupational duties to assess eligibility for benefits.

Fields

Field Description Example
insured_full_name Full legal name of the insured individual filing the claim. Michael D. Thompson
home_address Residential address of the insured. 789 Oakwood Dr, Springfield, IL, 62704
name_of_last_employer Name of the insured's most recent employer. Sunrise Construction Inc.
business_address Business address of the insured's last employer. 234 Industrial Way, Chicago, IL, 60601
usaa_number USAA membership identification number. 9988776655
home_telephone_number Primary contact phone number of the insured. 555-123-9876
insured_birth_date Date of birth of the insured individual. 07/22/1978
business_telephone_number Business contact phone number of the insured. 312-555-7890
disabling_condition Description of the current disabling condition and its cause. Lower back and knee injury from a construction accident.
month_of_accident_or_illness Month when the accident or illness occurred. 02
day_of_accident_or_illness Day when the accident or illness occurred. 15
year_of_accident_or_illness Year when the accident or illness occurred. 2024
month_stopped_working Month when the insured completely stopped working due to the disability. 02
day_stopped_working Day when the insured completely stopped working due to the disability. 17
year_stopped_working Year when the insured completely stopped working due to the disability. 2024
work_return_status Indicates whether the insured has returned to work, part-time, full-time, or has not returned. have not returned
physician_row_1_name Name of the first physician or medical practitioner consulted. Dr. Robert Meyers
physician_row_1_address Address of the first physician or medical practitioner consulted. 123 Wellness St, Boston, MA, 02110
physician_row_1_dates_consulted Date of consultation with the first physician. 02/20/2024
physician_row_2_name Name of the second physician or medical practitioner consulted. Dr. Susan Collins
physician_row_2_address Address of the second physician or medical practitioner consulted. 45 Medical Plaza, New York, NY, 10016
physician_row_2_dates_consulted Date of consultation with the second physician. 02/22/2024
physician_row_3_name Name of the third physician or medical practitioner consulted. Dr. rer tyj
physician_row_3_address Address of the third physician or medical practitioner consulted. 12 trefar, New York, NY, 10016
physician_row_3_dates_consulted Date of consultation with the third physician. 01/21/2022
hospital_row_1_name Name of the first hospital where the insured was confined. Springfield Medical Center
hospital_row_1_address Address of the first hospital where the insured was confined. 890 Main St, Springfield, IL, 62703
hospital_row_1_from Start date of the first hospital confinement. 02/18/2024
hospital_row_1_to End date of the first hospital confinement. 02/25/2024
hospital_row_1_reason Reason for the first hospital confinement. Surgery and rehabilitation for injury.
hospital_row_2_name Name of the second hospital where the insured was confined. Springfield Medical Center
hospital_row_2_address Address of the second hospital where the insured was confined. 890 Main St, Springfield, IL, 62703
hospital_row_2_from Start date of the second hospital confinement. 02/18/2024
hospital_row_2_to End date of the second hospital confinement. 02/25/2024
hospital_row_2_reason Reason for the second hospital confinement. Surgery and rehabilitation for injury.
occupation_prior_to_disability Job title held immediately before becoming disabled. Construction Site Supervisor
date_began_occupation Date when the insured started working in the listed occupation. 05/10/2010
unable_to_perform_duties Specific job duties the insured is unable to perform as a result of the disability. Heavy lifting, operating machinery, and working on scaffolding due to limited mobility and chronic pain.
prior_work_experience Details about prior work experience and educational background. Bachelor's Degree in Civil Engineering, 12 years of experience in construction site management.
remarks Additional notes or remarks from the insured. Ongoing physical therapy and treatment plan in progress.