ATTN UPS EMPLOYEES in Addition to Completing and 2024-2026

ATTN UPS EMPLOYEES In addition to completing and returning this form to TeamCare UPS employees must also call Aetna at 866-825-0186 to initiate your leave with UPS* SHORT-TERM DISABILITY CLAIM FORM - INITIAL REPORT OF DISABILITY FORM MUST BE COMPLETED IN FULL BEFORE PAYMENT IS CONSIDERED Remit To TeamCare PO Box 5107 Des Plaines IL 60017-5107 or Fax Form To 847-518-9757 SECTION 1 PARTICIPANT S INFORMATION Participant s Identification Number PLEASE PRINT Participant s Full Name Date of Birth Participant s Complete Address Employer Date of Accident If accident related please answer the following questions Where did the accident occur Home check one Work Auto Other How did the accident occur Is your disability in any way work related Yes No If yes please explain If you have been denied by Workers Compensation attach a copy of the denial* Authorization I hereby authorize any doctor hospital or insurance company to furnish and disclose all known facts. Signature of Participant SECTION 2 PHYSICIAN S STATEMENT Patient s Name Date Date Disability Began Diagnosis DO NOT SUBMIT FORM BEFORE THIS DATE All dates of treatment for this disability Was patient hospitalized Surgery date and procedure performed What is the treatment plan Is condition due to patient s employment For a pregnancy please give the estimated delivery date Briefly explain ACTUAL OR ESTIMATED RETURN TO WORK DATE REQUIRED Actual return to work date OR Physician s Signature Estimated return to work date Print Physician s Name Physician s Phone Number Date Form Completed SECTION 3 EMPLOYER S STATEMENT What was the employee s last day paid or compensated i*e* vacation What date did the employee actually return to work Do not use a future date Last day worked Was the employee on layoff Date of layoff Employer s Signature Date recalled Has a claim been filed for Workers Compensation related to this disability Print Employer s Name and Position Employer s Phone Number g g f f STD TeamCare-STD-Claim-Form-1-Initial-Report-of-Disability.doc 20190514 201908 HW8AA PROCEDURES TO FILE FOR SHORT TERM DISABILITY BENEFITS WITH TEAMCARE HOW DO I FILE FOR MY BENEFITS TEAMCARE Your Short-Term Disability Benefit provides a weekly payment as indicated in your Plan Benefit Profile. To receive these benefits you must be disabled as a result of a non-work-related injury or illness or unable to work due to pregnancy and you must be receiving regular care from your doctor. You must be actively employed and covered by the Plan when you become disabled* To begin receiving your weekly payments please follow the procedures below In order to begin the process you must complete and submit the TeamCare You can download and print the claim form from the TeamCare website at MyTeamCare.org or you can call 800-TEAMCARE to request a claim form be mailed or faxed* COMPLETING CLAIM FORM Sections 1 2 and 3 can be completed in any order. If you are concerned about your privacy TeamCare suggests that you obtain the Physician s Statement after your employer has completed the Employer Statement. Section 1 Must be completed by the employee SUBMITTING CLAIM FORM Once the claim form is completed you can either mail or fax claim to MAIL TeamCare Central States Health Fund PO Box 5107 Des Plaines IL 60017-5107 FAX 847 518-9757 PHYSICIANS UPDATES Once your disability payments begin you may be asked to submit a SHORT-TERM DISABILITY -CONTINUATION FORM to TeamCare with updates from your physician* Please return the form promptly to avoid delay in processing your payments. UPS Aetna UPS EMPLOYEES ONLY In addition to submitting your claim form to TeamCare UPS employees must also call Aetna at 866-825-0186 to initiate your leave with UPS* A medical note supporting your leave must be provided and Aetna will give you information explaining your additional responsibilities while on leave. Once on leave medical documents must be sent to Aetna every 90 calendar days to recertify your leave. That documentation can be uploaded to your claim at www.aetnadisability.com* General questions about your leave from UPS should be directed to Aetna at 866-825-0186. DO YOU WORK AT UPS IN NJ NY CA or RI UPS employees who work in NY or NJ must submit your claim through Aetna as follows Call 866 825 0186 to reach an Aetna Disability representative or Online at www.aetnadisability.com* short term disability program* A copy of that claim should then be submitted to TeamCare. What happens when I exhaust my weekly Short-Term Disability benefits Non-UPS Participants If you exhaust your Short-Term Disability benefits you may be eligible to make Cobra Self-Payments or receive an Extension of Benefits to continue coverage. Contact a TeamCare Benefits Specialist at 800-TEAMCARE for information* UPS Participants If you exhaust your Short-Term Disability benefits you may be eligible for Long-Term Disability benefits through UPS* To determine your eligibility for long-term disability please call 866-825-0186. QUESTIONS If you have questions please login into MyTeamCare.org and send a secure message question through the Message Center or call a Benefits Specialist at 800-TEAMCARE 832-6227 .