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Claimant's Disability Statement
Name of claimant
Email
Phone
Address
City
State
Date of birth (mm/dd/yyyy)
ZIP code
Contract number(s)
Answer the following nine questions, then sign and date on page 3.
1. Describe the nature of the impairment
Work-related?
Yes
No
Impairment began (mm/dd/yyyy) If accident, describe how the accident occurred
Impairment is the result of:
Accident
Sickness
2. Employment Information: Immediately prior to the date you are claiming disability, were you:
W2 employee - Complete Section A below and have your employer complete the Employment Statement on Page 9.
Homemaker/Unemployed/Retired - Complete Section B below. (Employment Statement on Page 9 is not needed,)
Self-Employed - Complete Section C on Page 2.
Section A - W2 Employee
Name of employer
Employment dates (mm/dd/yyyy)
to
Occupation and duties
Contact person
Phone
Address
City
State
ZIP code
Average monthly earned income prior to disability (gross) - $
Section B - Homemaker/Unemployed/Retired
List your activities, including the number of hours per day and days per week that you typically performed these activities just
prior to the time you are claiming disability benefits.
Activities
Hrs/Day
Days/Wk
Name of person(s) currently performing the activities that you are unable to perform
If retired: Date of retirement (mm/dd/yyyy) -
If unemployed: Date last worked (mm/dd/yyyy) -
Reason for unemployment Name of last employer (if unemployment began within the last 24 months)
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Phone number of last employer
Section C - Self-Employed
Name of business
Phone
Address
City
State
ZIP code
Describe the nature of your business (be specific)
How long have you owned this business?
How is your business organized?
Sole Owner/Proprietor
Partnership %
S Corporation
C Corporation
Limited Liability Corporation
Does your business pay any portion of your Thrivent Financial premium?
How are you compensated for your work (select all that apply)?
Based on your last federal tax return prior to disability:
Yes -
W2 wages
Net profit: $
%
No
1099 earnings
% of profits
Gross profit: $
What was your total earned income for the year? $
Note: Thrivent Financial may require financial records to verify earned income.
List the primary duties/responsibilities you were performing before disability began, including type and number of hours spent
doing these tasks each week. *Type: S = Supervisory, C = Clerical, P = Physical, or O=Other
Duties/Responsibilities
Type*
Hrs/Wk
If your duties vary throughout the year, explain 3. Secondary Occupation Information (complete if applicable)
Name of employer
Occupation title
Contact person
Employment dates (mm/dd/yyyy)
to
Average monthly earned income prior to disability (gross)
$
Phone
4. Select all of the benefits you have applied for and complete the additional information if you are receiving or may receive
payment from that benefit.
Monthly
Effective Date
Name and Phone Number of Payor
None
Amount
(mm/dd/yyyy)
Disability Income Policy(ies) $
Group Disability Coverage
$
Sick Pay
Vacation Pay $
Salary Continuation
$
Workers' Compensation
$
Railroad Retirement
$
Government Disability
$
Automobile/Liability
$
Veterans' Disability
$
Social Security
$
Disability
Retirement
Supplemental Income
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5. Date medically unable to perform regular occupation/activities (mm/dd/yyyy) Explain how this condition(s) limits your ability to work or perform your daily activities.
6. Have you returned to work/activities in any capacity?
Yes
No
If yes, on what date (mm/dd/yyyy)?
Full time
Part time
List what occupation/activities were performed, if applicable.
7. First physician seen who provided treatment for this condition
Phone
Name of doctor first seen
City
State
Dates treated (mm/dd/yyyy)
8. Hospital where treatment was received and/or additional physicians providing treatment for this condition
Name of hospital or additional treating physician
Phone
City
State
Dates treated (mm/dd/yyyy)
Name of additional treating physician
City
Phone
State
Dates treated (mm/dd/yyyy)
9. Medical Provider Information (for claims within two years from the date contract was issued)
Name of other physician seen in the last 10 years
City
State
Phone
Dates treated (mm/dd/yyyy)
Name of other physician seen in the last 10 years
City
State
Phone
Dates treated (mm/dd/yyyy)
The claimant must sign and date this form. Failing to sign or altering the authorization may limit Thrivent Financial's
ability to review your claim or pay claim benefits.
For your protection, state laws require the following to appear on this form: Any person who, knowingly and with intent to
defraud or deceive any insurance company or other person, files or facilitates the filing of a statement of claim containing
any materially false information, or conceals information concerning any fact material to the statement, may be guilty of
insurance fraud, which may be a felony crime, subject to civil penalties or criminal prosecution, including substantial fines
and/or confinement in prison.
I swear that the statements and answers provided on this form are true and complete to the best of my knowledge.
Signature of claimant
X
Relationship, if other than claimant
Date (mm/dd/yyyy)
If a cognitive impairment exists and a durable power of
attorney for finances has been appointed, send a copy
of that document.
Mail completed form to: Attn Disability Income Claims, Thrivent Financial, 4321 N Ballard Road, Appleton WI 54912-8075
OR Fax: 800-225-2264
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Direct Deposit Authorization
Thrivent Financial provides the option of having your monthly disability payment directly deposited into your personal bank
account. If you are interested in this service, complete the information below.
Note: Funds can only be sent to a bank account in the insured's name. Funds cannot be sent to a family member (unless
joint account with the insured), Power of Attorney, trust, or any business you own.
All sections of this form must be completed even if your premium is being withdrawn from the same account.
I authorize Thrivent Financial to make this electronic deposit and, if necessary, corrections to my financial institution account.
My authorization is valid for electronic deposits and corrections that comply with U.S. law. U.S. law grants me certain rights
when I request an electronic deposit. These laws also regulate how electronic deposits and corrections are made to my
financial institution account. This authorization shall remain in full force and effect until I revoke it by giving 10 days prior
notice to Thrivent Financial.
New
Change
Contract number
Name
Deposit my contract benefits into the following account:
Checking
Savings
Transit number (9 digit ABA number) - Consult your bank for the correct one.
Account number
Name of financial institution
Phone of financial institution
Address
City
State
Name in which account is held
The benefit payment will be sent by check until direct deposit can be established.
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ZIP code
Health and Other Personal
Information Authorization
(This authorization complies with
the HIPAA Privacy Rule.)
Name (print title, first, middle, last name and suffix, as applicable)
Date of birth (mm/dd/yyyy)
Contract number
This authorization applies to Thrivent Financial for Lutherans, Thrivent Life Insurance Company, Thrivent Insurance Agency
Inc. and third party administrator LTCG, their employees, representatives, agents, reinsurers and any other persons
performing business, legal, medical or insurance services for them or on their behalf, hereafter called "You" or "Your."
For the purpose of determining my eligibility for insurance, payment, or health care, or for any other use, collection or
disclosure permitted by law, You may need to obtain, use or disclose any and all information about my physical and mental
health, including but not limited to services for preventive, diagnostic and therapeutic care, tests, counseling and medical
prescriptions; and non-health information about me including but not limited to financial, insurance, credit, occupational,
avocational and driving history.
I authorize any health care professional, medical facility, pharmacy benefit manager, mental health facility, laboratory,
paramedical facility, medical examiner, medical records service, prescription history clearinghouse, other insurer, insurance
broker, Your affiliate, health care component of Your company, Department of Motor Vehicles, consumer reporting agency,
MIB, Inc., employer, family member and acquaintance to provide information about me, including my entire medical record,
to You. By my signature below, I acknowledge that any prior agreement I have made to restrict or limit the disclosure
of information about my health does not apply to this authorization.
I authorize You to disclose information about me to any insurance broker and other insurer approved by You for the purpose
of securing insurance for me. Information about my health may be released as required or permitted by law such as to
MIB, Inc. in an effort to deter fraud, misrepresentation or criminal activity. Health information about me, which is used or
disclosed pursuant to this authorization, may be subject to redisclosure by the recipient, and may no longer be protected
under federal law.
This authorization is valid for 24 months following the date of my signature shown below. A copy, image or facsimile of this
authorization is as valid as the original. I have the right to revoke this authorization in writing as outlined in the Privacy of
Information about Your Health notice. I acknowledge that such a revocation is not effective to the extent You have relied on
the use or disclosure of my health information or You have a legal right to contest the insurance contract or a claim under
the insurance contract.
I understand that the application which holds personally identifiable health information and financial information will be
attached to the contract for purposes of contract issuance. I understand that if this contract is owned by someone other than
me a copy of the contract which contains the application will be provided to the owner.
I understand You may not be able to determine my eligibility for insurance if I do not agree to the terms of this authorization.
I have read this authorization, and I agree to its terms as indicated by my signature below.
I am entitled to receive a copy of this authorization.
Signature of proposed insured or
personal representative
Date signed
(mm/dd/yyyy)
X
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Description of personal
representative's authority to act
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Attending Physician's Statement
Any cost for completion of the claim form is the responsibility of the patient.
Section 1 - Patient Information (to be completed and signed by the patient)
Name of patient
Date of birth (mm/dd/yyyy)
Contract number(s)
Occupation and primary work duties or homemaker/unemployed/retired activities
I hereby authorize my physician to release any information acquired in the course of my examination(s) or treatment.
Signature of patient
Date (mm/dd/yyyy)
X
Section 2 - Medical History (to be completed and signed by the attending physician)
This report assists us in making a disability determination. Your patient is depending on your prompt and detailed information.
1. History
Date symptoms first appeared or date of accident (mm/dd/yyyy) Yes
No Has the patient ever had the same or similar condition?
If yes, explain.
Yes
No Is the condition work-related?
Yes
No Has the patient been hospitalized?
If hospitalized, give dates of confinement (mm/dd/yyyy): Admitted -
Discharged -
Name of hospital
Phone
Address
City
State
ZIP code
Name of physician who referred patient to you
Phone
Name(s) of other health care providers the patient has been referred to
Phone(s)
2. Diagnosis and Prognosis
Primary ICD -
Diagnosis -
Secondary ICD -
Diagnosis -
Date patient became medically unable to perform activities listed above (mm/dd/yyyy) Yes
No Did you treat the patient on this date?
Initial date of treatment for this condition(s) at your clinic or by you (mm/dd/yyyy) Most recent date of treatment for this condition(s) (mm/dd/yyyy) Next date of treatment for this condition(s) (mm/dd/yyyy) Yes
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No Is the patient still under your care for this condition(s)?
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3. Extent of Disability and Treatment
No Is the patient medically able to return to the above noted occupation/activities?
Full time
Part time
If yes, provide return date (mm/dd/yyyy) Yes
If no, when will the patient be able to return to the above noted occupation/activities (in months)?
1
2
Yes
No
3
4
5
6
12
Permanently unable to work
Do you feel the patient is medically able to perform another occupation?
Full time
If yes, provide return date (mm/dd/yyyy) -
Part time
If no, anticipated date patient will be medically able to perform another occupation (mm/dd/yyyy) Current limitations/restrictions (be as specific and as quantitative as possible, i.e. lifting = how many pounds):
Lifting/Carrying
Standing
Driving
Squatting
Bending/Twisting
Overhead
Climbing
Sitting
Psychological
Other
Current and recommended treatment plans
Walking
Date surgery performed/anticipated
(mm/dd/yyyy)
Medications (names and dosages)
Objective findings
Yes
No
Do you believe the patient is competent enough to endorse checks and direct the use of proceeds thereof?
4. Physician Information
Yes
No Have you completed claim forms for other disability income or workers' compensation insurance carriers?
Company Name
Address
Name of attending physician (including specialty/degree)
Tax ID number
Address
City
Phone
Fax
State
ZIP code
For your protection, state laws require the following to appear on this form: Any person who, knowingly and with intent to
defraud or deceive any insurance company or other person, files or facilitates the filing of a statement of claim containing
any materially false information, or conceals information concerning any fact material to the statement, may be guilty of
insurance fraud, which may be a felony crime, subject to civil penalties or criminal prosecution, including substantial fines
and/or confinement in prison.
I swear that the statements and answers provided on this form are true and complete to the best of my knowledge.
Signature of physician
Date (mm/dd/yyyy)
X
Name of contact person for any questions regarding the information provided on this form
Phone
Mail completed form to: Attn Disability Income Claims, Thrivent Financial, 4321 N Ballard Road, Appleton WI 54912-8075
OR Fax: 800-225-2264
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Employment Statement
Any cost for completion of the Employment Statement is the responsibility of the employee.
Section 1 - Employee Identification Information (to be completed and signed by the employee)
Name of employee
Date of birth (mm/dd/yyyy) Contract number(s)
I hereby authorize my employer to release any information acquired in the course of my employment.
Signature of employee
Date (mm/dd/yyyy)
X
Section 2 - Employment Information (to be completed and signed by the employer)
Date of hire (mm/dd/yyyy) Yes
No Has the insured returned to work?
Full time
Part time
If yes, returned:
Last day worked, prior to disability (mm/dd/yyyy) If yes, date (mm/dd/yyyy) Regular occupation
Different occupation
To:
If the insured has not returned to work, what is the expected date of return (mm/dd/yyyy)?
Yes
No Are you holding the job open?
If yes, effective date (mm/dd/yyyy) Yes
No Has the insured retired or resigned?
Do you pay any portion of the insured's Thrivent Financial disability insurance premium?
Yes Work History and Earnings for the Last Two Years (list most current position first):
Job Title
Start Date End Date
Average Gross Monthly
Hrs/Week
Income
%
No
Job Duties/Physical Requirements
(attach job description)
$
$
$
$
Other Insurance Coverage:
Group Disability
Yes
No
Has a claim been filed?
Policy number
Name of carrier
Phone number of carrier
Monthly benefit
Dates benefits began (mm/dd/yyyy) Effective date of coverage
Worker's Compensation
Yes
No
Waiting period:
Accident Sickness Maximum period:
Accident Sickness -
Yes, amount - $
Is the insured receiving salary continuation or sick pay?
When did benefits begin?
Length of time benefits will continue?
No
For your protection, state laws require the following to appear on this form: Any person who, knowingly and with intent to
defraud or deceive any insurance company or other person, files or facilitates the filing of a statement of claim containing
any materially false information, or conceals information concerning any fact material to the statement, may be guilty of
insurance fraud, which may be a felony crime, subject to civil penalties or criminal prosecution, including substantial fines
and/or confinement in prison.
I swear that the statements and answers provided on this form are true and complete to the best of my knowledge.
Signature of employer
Date (mm/dd/yyyy)
X
Print name
Title
Company name
Phone
Fax
Mail completed form to: Attn: Disability Income Claims, Thrivent Financial, 4321 N. Ballard Road, Appleton WI 54912-8075
OR Fax: 800-225-2264
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