Supplemental Member Statement Plan Form (Page 2 of 2) in pdf

Residual Disability

If you have returned to work in your pre-disability occupation, you will need to provide documentation of your prior and

current Individual Monthly Production in order to determine your eligibility for a Residual Disability Monthly Income Benefit.

Required documentation:

1. Copies of your individual monthly production reports for the 24 month period just prior to the date you became

disabled.

2. Copies of your individual monthly production reports beginning with the month in which you returned to work on a part-

time basis.

Please ensure these reports include description of service with applicable Current Dental Terminology (CDT) Codes and

charges for the services provided.

Are you handling your own business affairs?  Yes  No

If no, please provide documentation showing who has legal Power of Attorney, unless previously provided.

If you are receiving other disability benefits, has there been a change in status since your last report? Yes __ No___

If Yes, please explain:

I hereby certify that I have carefully read the foregoing questions and fully understand them, and that each answer is true

and complete to the best of my knowledge and belief. I further understand Great-West (the Company) or its representative

may request from time to time any documents which I have in my possession, supporting this statement, and I hereby agree

to furnish them upon request. It is understood that the Company will make an independent investigation of this claim.

Authorization

I hereby authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility,

insurance company, the Medical Information Bureau, or other organization, institution or person, having any records or

knowledge of any illness, injury, medical history or treatment I have had, to furnish Great-West (the Company) all such

information.

The information requested by the Company may include information available as to diagnosis, treatment and prognosis with

respect to any physical or mental condition, including consultations after the date this authorization is signed.

Any other

information the Company believes to be necessary to determine eligibility for insurance benefits may also be requested.

The information collected will be used for determining eligibility for benefits under any policies issued by the Company and

for other business purposes in connection with the insurance relationship. All or part of the information collected may be

sent to the Company’s reinsurers, and to other insurance companies with whom I have insurance or to whom I apply for

insurance. Information may be sent to persons performing business or legal functions of the Company or to persons

conducting research studies or audits.

The authorization shall continue to be valid for twelve months from the date it is signed. A photocopy of this signed

authorization shall be as valid as the original. I may request a copy of this authorization.

State statutes in Idaho, New York, and Florida require the following language: Any person who knowingly and with intent to

defraud any insurance company or other person files a statement of claim containing any materially false or misleading

information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a

fraudulent insurance act, which is a crime (in Florida, a felony of the third degree.)

Printed Name

Signature*

Date

*If this form is signed by someone other than the Member, please provide name and relationship.

Supplemental Member Statement Plan Form Page 2