Supplemental Member Statement Plan Form
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1
2Disability Income Plan
P.O. Box 17410
Denver, CO 80217-0410
1-866-257-0707 - Tel
L
1-303-737-2879 - Fax
SUPPLEMENTAL MEMBER STATEMENT PLAN 1105
Name: _____________________________ Date of Birth: _________ ADA# _________________ Claim# _____________
Present Address: ____________________________________________________________________________________
City: __________________ State: _________ Zip Code: ______________ Telephone No. : _________________________
Check here if Change of Address
Progress
Has there been any change in your condition since your last report? Yes No
1.
2.
If yes, please explain the nature and extent of the change in condition:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
3.
Briefly describe how your disabling condition impacts your daily activities:
_________________________________________________________________________________________
_________________________________________________________________________________________
Treatment
1. Please provide complete information about the physicians you have seen during the past 12 months.
Doctor’s full name, address and telephone number:
Date of your last visit:
_________________________
_________________________________________
Date of you next visit:
_________________________
_________________________________________
Condition being treated: _________________________
_________________________________________
_____________________________________________
Doctor’s full name, address and telephone number:
Date of your last visit:
_________________________
_________________________________________
Date of you next visit:
_________________________
_________________________________________
Condition being treated: _________________________
_________________________________________
_____________________________________________
2. Have you been hospital confined since your last report? Yes No
If yes, please list name and address of hospital:
________________________________________________________________________________________
________________________________________________________________________________________
3. Condition being treated: ____________________________________________________________________
Date of Admission: ____________________________ Date of Discharge: ____________________________
Work Activities
Have you returned to work in any capacity since your last report? Yes No Date returned: ____________
1.
If yes, is this a new occupation? Yes No
2.
Job Title: _________________________________________
3.
Describe your current work activities and schedule:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
4.
Do you participate in any volunteer activities? Please describe:
_______________________________________________________________________________________
_______________________________________________________________________________________
M4024 (Rev 09/12)
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