INSTRUCTIONS FOR COMPLETION OF DISABILITY CLAIM FORM
Bottom front section of form GJ-840 Rev 9-94 should be completed in full (please type or print) exactly as shown, and signed by the Store Manager. Failure to complete any section as shown below will result in a delay for your Associate.
Name of Employee - Associate’s full name
Group Policy No. - 54987
Certi. No. - Associate’s Social Security Number
Br. No. - Store Number
Date Employed - Associate’s Date of Employment
Date Insured – 1st of Month following 3 months fulltime employment (or date Associated
enrolled, if he/she waived when originally eligible)
Ins. Class - 1
Did Employee Cease Work… Yes or No (Usually Yes)
If No, Please Explain – (Call Human Resources)
Date Last Worked – Date last actually at work prior to disability
Date Returned – First date actually back at work
Total Basic Salary Paid – Total Salary three months prior to disability
Will Salary be Paid During Disability? – No
Thru what date? – (Leave blank)
Employee’s Weekly Basic Salary at Disability Date – (If Associate is Hourly, cross out
“weekly” and write “hourly” and supply hourly rate. If Associate is Weekly Salaried,
supply weekly salary.)
Employee Entitled to Benefits Under Workers’ Comp…(If not, check “no.” If so, check
“yes”)
Weekly Amount (If “yes” to previous question, contact your Human Resources Generalist. If
“no”, leave blank)
Date of Last Salary Increase – Effective date (month, date, year)
Amount of Salary Included…(leave blank)
Are Enrollment Cards Kept in Your files? – No
Insured’s number of hours per scheduled week – 40 (Use 40, regardless of actual number of
hours)
Lines 1, 2 and 3 – (Leave blank)
Employee Occupation – Associate’s job title
Employee Soc. Sec. # - Associate’s Social Security #
Policyholder’s Phone # - Your store phone #, including area code
Signature of Policyholder’s Authorized Representative – Store Manager’s signature
Title – Store Manager
Date – Date you complete and sign form
Name of Policyholder - Stein Mart