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Fill Out Your Si 3379 Cta Form

The SI 3379 CTA form is a crucial document used for applying for disability benefits through Standard Insurance Company. This form comprises various sections that require detailed information about your condition, employment, and medical history. To ensure your application processes smoothly, make sure to fill out every section completely and accurately.

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Article Structure

The SI 3379 CTA form is a crucial tool in the process of filing a disability benefits claim with Standard Insurance Company. This form package consists of four essential documents, each with specific requirements that must be meticulously completed to ensure timely processing. It all starts with the Employee’s Statement, where you need to provide comprehensive details about your current condition, work-related history, and any relevant medical treatments. The second part involves giving authorization for the release of personal and medical information, including details from mental health providers if applicable. A vital component of this process is the Attending Physician’s Statement, which requires input from your healthcare provider, ensuring that all medical information is current and correctly represented. Lastly, the Employer’s Statement must be filled out by your employer to provide necessary context about your job and any work-related conditions that may contribute to your disability claim. Attention to detail is paramount; forms received with unanswered questions or incomplete sections can lead to delays, so it’s essential to fill every space, marking 'NA' for non-applicable items. By carefully following the outlined instructions, you can facilitate a smoother claims process and increase the chances of a favorable outcome.

Si 3379 Cta Example

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Standard Insurance Company – CTA Beneﬁts and Services PO Box 2773 Portland OR 97208

Tel 800.522.0406 Fax 888.414.0390

Disability Beneﬁts Claim Packet Instructions

PLEASE READ CAREFULLY

Your application for beneﬁts consists of four forms. Every space on these forms should be ﬁlled in to avoid delay in processing your application. If a section does not apply, or information is not available, “NA” should be written in the space so that we know you did not overlook that particular question. If a form is received incomplete, it may be returned for completion.

The four forms are:

1.The Employee’s Statement

●Answer every question completely. Be sure to use the appropriate section for injury, sickness or pregnancy. If a question does not apply to you write “NA”.

●

Use an additional page, if necessary, to give full and complete answers.

Attach copies of any Social Security, Public Employees Retirement System, State Teachers Retirement System, Workers’ Compensation or other beneﬁt determinations you have received. If you have applied for any other beneﬁts but have not yet received them, please send a copy of the application receipt. This information is needed to accurately calculate your monthly beneﬁts. If you are unable to make copies of these documents please send the originals. We will photocopy and return them to you promptly.

●Remember to sign and date your statement. An unsigned or undated statement will be returned to you.

2.The Authorization to Obtain and Release Information

The Authorization to Obtain and Release Psychotherapy Notes

●Please sign and date the Authorization to Obtain and Release Information and attach it to the Employee’s Statement. Your signature lets Standard Insurance Company (The Standard) get the information about you that we need to determine your eligibility for beneﬁts. The Authorization to Obtain and Release Information also lets The Standard release this information to speciﬁc persons.

If you have seen or been treated by a Psychiatrist, Psychotherapist, Psychologist, Clinical Social Worker (MSW, MCSW, etc.), or any other provider of treatment for a mental condition, please sign and return the Authorization to Obtain and Release Information and the Authorization to Obtain and Release Psychotherapy Notes.

You will receive copies of these Authorizations upon your request.

3.The Attending Physician’s Statement

●

Part A should be completed by you.

Part B should be completed by your physician. If you have seen more than one physician for your disability, a statement should be completed by each physician. Your physician(s) should mail the completed form directly

to The Standard.

4.The Employer’s Statement

● This form should be completed by your employer, who will mail it to The Standard.

You are responsible for making sure all required forms are completed and returned to our ofﬁce. If you have any questions,

our ofﬁce is here to help you.

SI 3379 CTA

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		Reset
Standard Insurance Company	Return to page 1
Standard Insurance Company
CTA Beneﬁts and Services

	Disability Insurance
PO Box 2773 Portland OR 97208	Disability Insurance
Tel 800.522.0406 Fax 888.414.0390	Employee’s Statement

Please print clearly. Form may be returned for unanswered questions.

1. CLAIMANT

Last Name:

First Name:

Middle Name:

Sufﬁx:

Social Security No.:

Address:

City:

State:

Zip Code:

Phone No.:

Patient No.:

Birthdate:

Gender:  Male

 Female

Height:

Weight:

Spouse/Domestic Partner Information

Last Name:

First Name:

Middle Name:

Sufﬁx:

Date of Birth:

No. of dependent children:

Birthdate of youngest:

Did you receive a Certiﬁcate of Insurance? Yes  No

Did you receive a Brochure?

Yes

 No

If no, please contact The Standard.

2. EMPLOYMENT

School District Name:

Group Policy No.:

Address:

City:

State:

Zip Code:

Phone No.:

Job title:

Describe your Job Duties:

Is your disability work-related?

Yes

 No

Date of injury:

Have you ﬁled a Workers’ Compensation claim?

Yes

 No

If Yes, W.C. claim number:

Last full day at work:

Date you became unable to work at your occupation as a result of disability:

Are you now or have you worked at your occupation or any other occupation since the date of your injury?

Yes

 No

If yes, provide name of employer and

dates of employment:

Employer Name:

Phone No.:

Address:

City:

State:

Zip Code:

Employment Start Date:

Employment End Date:

Are you self-employed at any activity?

Yes

 No

Date you resumed part-time work:

Work

Phone:

Extension:

Date you resumed full-time work:

Work

Phone:

Extension:

SI 3379 CTA

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Standard Insurance Company

CTA Beneﬁts and Services

PO Box 2773 Portland OR 97208

Tel 800.522.0406 Fax 888.414.0390

Disability Insurance Employee’s Statement

Claimant’s Name:

3.SICKNESS Please list all illnesses which contribute to your being unable to work at your occupation.

Illness:

Date First Noticed:

Illness:

Date First Noticed:

State what you believe caused your illness.

Describe your symptoms:

Have you ever had the same condition or a related illness before? Yes

 No

Date:

4. INJURY

Describe Injuries:

Cause of Injuries:

Date injury occurred:

Time injury occurred:

Location where injury occurred:

5. PREGNANCY

Date you expect to cease work:

Expected delivery date:

Actual delivery date:

Expected return to work date:

Please indicate any foreseeable complications.

6. ATTENDING PHYSICIAN List all physicians consulted for this injury or illness. Use separate sheet, if needed.

Physician’s Last Name:

First Name:

Specialty:

Phone No.:

Address:

City:

State:

Zip Code:

Date ﬁrst consulted for this injury or illness:

Date last consulted:

Physician’s Last Name:

First Name:

Specialty:

Phone No.:

Address:

City:

State:

Zip Code:

Date ﬁrst consulted for this injury or illness:

Date last consulted:

Physician’s Last Name:

First Name:

Specialty:

Phone No.:

Address:

City:

State:

Zip Code:

Date ﬁrst consulted for this injury or illness:

Date last consulted:

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Standard Insurance Company

CTA Beneﬁts and Services

PO Box 2773 Portland OR 97208

Tel 800.522.0406 Fax 888.414.0390

Disability Insurance Employee’s Statement

Claimant’s Name:

7. HOSPITAL If you were hospitalized for this condition, please complete. Please attach copy of hospital bill if available.

Hospital Name:

Address:

City:			State:	Zip Code:
From:	through:	Reason for hospitalization:
From:	through:	Reason for hospitalization:

8. HISTORY List all illnesses or injuries for which you have received treatment over the past ﬁve years. Use separate sheet if needed.

Ailment:

Date of treatment:

Physician’s Last Name:

First Name:

Address:

City:

State:

Zip Code:

Ailment:

Date of treatment:

Physician’s Last Name:

First Name:

Address:

City:

State:

Zip Code:

Ailment:

Date of treatment:

Physician’s Last Name:

First Name:

Address:

City:

State:

Zip Code:

Ailment:

Date of treatment:

Physician’s Last Name:

First Name:

Address:

City:

State:

Zip Code:

Ailment:

Date of treatment:

Physician’s Last Name:

First Name:

Address:

City:

State:

Zip Code:

Ailment:

Date of treatment:

Physician’s Last Name:

First Name:

Address:

City:

State:

Zip Code:

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Standard Insurance Company

CTA Beneﬁts and Services

PO Box 2773 Portland OR 97208

Tel 800.522.0406 Fax 888.414.0390

Disability Insurance Employee’s Statement

Claimant’s Name:

DEDUCTIBLE INCOME/INCOME FROM OTHER SOURCES

Your Group Disability plan is designed so that the income you receive from The Standard and other sources (Social Security, Workers’ Compensation and other beneﬁts as described in your Group Policy) will equal the percentage described in your Group Policy. You should check your Group Policy to determine how other beneﬁts may impact your disability beneﬁts. You must send The Standard copies of all of your beneﬁt determinations and related determinations. The policy under which you are insured may require that The Standard beneﬁt payment be reduced by actual or estimated beneﬁts payable from additional sources.

9. DEDUCTIBLE INCOME

Have you applied for or are you receiving

Applied

Receiving

Date Applied

Amount Received

Effective

beneﬁts from:

Yes No

For

Weekly

Monthly

Date

a. Social Security

 

 

b. Workers’ Compensation

 

 

c. State Disability Insurance

 

 

d. Retirement or Pension (Employer, PERS, STRS, etc.)

 

 

Please specify type

e. Other

 

 

(e.g., unemployment or union beneﬁts, etc.)

Please send copies of any letters or notices approving or denying beneﬁts.

10. INCOME FROM OTHER SOURCES

Are you receiving income from:

Effective Date

Daily Amount Received

Limit Date

a. Substitute Differential Pay

b. Fully Paid Sick Leave

Acknowledgement

I hereby certify that the answers I have made to the foregoing questions are both complete and true to the best of my knowledge and belief. I acknowledge that I have read the applicable fraud notice on page 6 of this form.

SIGNATURE

DATE

SI 3379 CTA

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Standard Insurance Company

CTA Beneﬁts and Services

PO Box 2773 Portland OR 97208

Tel 800.522.0406 Fax 888.414.0390

Disability Insurance Claim Form Fraud Notices

Some states require us to provide the following information to you:

ALABAMA, MARYLAND AND RHODE ISLAND RESIDENTS

Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or beneﬁt or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to ﬁnes and conﬁnement in prison.

CALIFORNIA RESIDENTS

For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to ﬁnes and conﬁnement in state prison.

COLORADO RESIDENTS

It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, ﬁnes, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to the policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

DISTRICT OF COLUMBIA RESIDENTS

WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or ﬁnes. In addition, an insurer may deny insurance beneﬁts, if false information materially related to a claim was provided by the applicant.

FLORIDA RESIDENTS

Any person who knowingly and with intent to injure, defraud or deceive an insurance company, ﬁles a statement of claim or an application containing false, incomplete or misleading information is guilty of a felony of the third degree

NEW JERSEY RESIDENTS

Any person who knowingly ﬁles a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

NEW YORK RESIDENTS

Any person who knowingly and with intent to defraud any insurance company or other person ﬁles an application for insurance or statement of claim, containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to civil penalty not to exceed ﬁve thousand dollars and the stated value of the claim for each such violation.

PENNSYLVANIA RESIDENTS

Any person who knowingly and with intent to defraud any insurance company or other person ﬁles an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

ALL OTHER RESIDENTS

Some states require us to inform you that any person who knowingly and with intent to injure, defraud or deceive an insurance company, or other person, ﬁles a statement containing false or misleading information concerning any fact material hereto commits a fraudulent insurance act which is subject to civil and/or criminal penalties, depending upon the state. Such actions may be deemed a felony and substantial ﬁnes may be imposed.

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Standard Insurance Company

CTA Beneﬁts and Services

Return to page 1

PO Box 2773 Portland OR 97208

Tel 800.522.0406 Fax 888.414.0390

Authorization to Obtain and Release Information

I AUTHORIZE THESE PERSONS having any records or knowledge of me or my health:

•Any physician, medical practitioner or health care provider.

•Any hospital, clinic, pharmacy or other medical or medically related facility or association.

•Kaiser Permanente.

•Any insurance company or annuity company.

•Any employer, policyholder or plan sponsor.

•Any organization or entity administering a beneﬁt or leave program (including statutory beneﬁts) or an annuity program.

•Any educational, vocational or rehabilitation counselor, organization or program.

•Any consumer reporting agency, ﬁnancial institution, accountant, or tax preparer.

•Any government agency (for example, Social Security Administration, Public Retirement System, Railroad Retirement Board, Workers’ Compensation Board, etc.).

TO GIVE THIS INFORMATION:

•Charts, notes, x-rays, operative reports, lab and medication records and all other medical information about me, including medical history, diagnosis, testing and test results. Prognosis and treatment of any physical or mental condition, including:

•Any disorder of the immune system, including HIV, Acquired Immune Deﬁciency Syndrome (AIDS) or other related syndromes or complexes.

•Any communicable disease or disorder.

•Any psychiatric or psychological condition, including test results, but excluding psychotherapy notes. Psychotherapy notes do not include a summary of diagnosis, functional status, the treatment plan, symptoms, prognosis and progress to date.

•Any condition, treatment, or therapy related to substance abuse, including alcohol and drugs.

and:

•Any non-medical information requested about me, including such things as education, employment history, earnings or ﬁnances, return to work accommodation discussions or evaluations, and eligibility for other beneﬁts or leave periods including, but not limited to, claims status, beneﬁt amount, payments, settlement terms, effective and termination dates, plan or program contributions, etc.

TO STANDARD INSURANCE COMPANY, THE STANDARD LIFE INSURANCE COMPANY OF NEW YORK, THE STANDARD BENEFIT ADMINISTRATORS AND THEIR AUTHORIZED REPRESENTATIVES (referred to as “The Companies”, individually and collectively), AND MY EMPLOYER’S ABSENCE MANAGEMENT PROGRAM ADMINISTRATOR (“Absence Manager”).

•I acknowledge that any agreements I have made to restrict my protected health information do not apply to this authorization and I instruct the persons and organizations identiﬁed above to release and disclose my entire medical record without restriction.

•I understand that each of The Companies and Absence Manager will gather my information only if they are administering or deciding my disability or leave of absence claim(s), and will use the information to determine my eligibility or entitlement for beneﬁts or leave of absence.

•I understand that I have the right to refuse to sign this authorization and a right to revoke this authorization at any time by sending a written statement to The Companies and Absence Manager, except to the extent the authorization has been relied upon to disclose requested records. A revocation of the authorization, or the failure to sign the authorization, may impair The Companies and Absence Manager’s ability to evaluate or process my claim(s), and may be a basis for denying or closing my claim(s) for beneﬁts or leave of absence.

•I understand that in the course of conducting its business The Companies and Absence Manager may disclose to other parties information about me. They may release information to a reinsurer, a plan administrator, plan sponsor, or any person performing business or legal services for them in connection with my claim(s). I understand that The Companies and Absence Manager will release information to my employer necessary for absence management, for return to work and accommodation discussions, and when performing administration of my employer’s self-funded (and not insured) disability plans.

•I understand that The Companies and Absence Manager comply with state and federal laws and regulations enacted to protect my privacy. I also understand that the information disclosed to them pursuant to this authorization may be subject to redisclosure with my authorization or as otherwise permitted or required by law. Information retained and disclosed by The Companies and Absence Manager may not be protected under the Health Insurance Portability and Accountability Act [HIPAA].

•I understand and agree that this authorization as used to gather information shall remain in force from the date signed below:

•For Standard Insurance Company, the duration of my claim(s) or 24 months, whichever occurs ﬁrst.

•For The Standard Life Insurance Company of New York, the duration of my claim(s) or 24 months, whichever occurs ﬁrst.

•For The Standard Beneﬁt Administrators, the duration of my claim(s) administered by The Standard Beneﬁt Administrators or 24 months, whichever occurs ﬁrst.

•For Absence Manager, 24 months.

•I understand and agree that The Companies and Absence Manager may share information with each other regarding my disability and leave of absence claim(s). This authorization to share information shall remain valid for 12 months from the date signed below.

•I acknowledge that I have read this authorization and the New Mexico notice on page 8. A photocopy or facsimile of this authorization is as valid as the original and will be provided to me upon request.

Name (please print)			Social Security No.
Signature of Claimant/Representative			Date

If signature is provided by legal representative (e.g., Attorney in Fact, guardian or conservator), please attach documentation of legal status.

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Standard Insurance Company

CTA Beneﬁts and Services

PO Box 2773 Portland OR 97208

Tel 800.522.0406 Fax 888.414.0390

Authorization to Obtain and Release Information

Standard Insurance Company is a licensed insurance company in all states except New York. The Standard Life Insurance Company of New York is an insurance company licensed only in New York. An absence manager may be hired by your employer and may be one of The Companies.

FOR RESIDENTS OF NEW MEXICO

The state of New Mexico requires Standard Insurance Company to provide you with the following information pursuant to its Domestic Abuse Insurance Protection Act.

The Authorization form allows Standard Insurance Company to obtain personal information as it determines your eligibility for insurance beneﬁts. The information obtained from you and from other sources may include conﬁdential abuse information. “Conﬁdential abuse information” means information about acts of domestic abuse or abuse status, the work or home address or telephone number of a victim of domestic abuse or the status of an applicant or insured as a family member, employer or associate of a victim of domestic abuse or a person with whom an applicant or insured is known to have a direct, close personal, family or abuse-related counseling relationship. With respect to conﬁdential abuse information, you may revoke this authorization in writing, effective ten days after receipt by Standard Insurance Company, understanding that doing so may result in a claim being denied or may adversely affect a pending insurance action.

Standard Insurance Company is prohibited by law from using abuse status as a basis for denying, refusing to issue, renew or reissue or canceling or otherwise terminating a policy, restricting or excluding coverage or beneﬁts of a policy or charging a higher premium for a policy.

Upon written request you have the right to review your conﬁdential abuse information obtained by Standard Insurance Company. Within 30 business days of receiving the request, Standard Insurance Company will mail you a copy of the information pertaining to you. After you have reviewed the information, you may request that we correct, amend or delete any conﬁdential abuse information which you believe is incorrect. Standard Insurance Company will carefully review your request and make changes when justiﬁed. If you would like more information about this right or our information practices, a full notice can be obtained by writing to us.

If you wish to be a protected person (a victim of domestic abuse who has notiﬁed Standard Insurance Company that you are or have been a victim of domestic abuse) and participate in Standard Insurance Company’s location information conﬁdentiality program, your request should be sent to Standard Insurance Company.

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Standard Insurance Company

CTA Beneﬁts and Services

Return to page 1

PO Box 2773 Portland OR 97208

Tel 800.522.0406 Fax 888.414.0390

Authorization to Obtain and Release Psychotherapy Notes

I AUTHORIZE THESE PERSONS having any records or knowledge of me or my health:

•Any physician, medical practitioner or health care provider.

•Any hospital, clinic, pharmacy or other medical or medically related facility or association.

•Kaiser Permanente.

•Any insurance company.

•Any organization or entity administering a beneﬁt or leave program (including statutory beneﬁts)

•Any government agency (for example, Social Security Administration, Public Retirement System, Railroad Retirement Board, Workers’ Compensation Board, etc.).

TO GIVE THIS INFORMATION:

•Notes recorded by a health care provider who is a mental health professional documenting or analyzing the contents of conversation(s) during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of my medical record.

•I understand and agree that this authorization as used to gather information shall remain in force from the date signed below:

•For Standard Insurance Company, the duration of my claim(s) or 24 months, whichever occurs ﬁrst.

•For The Standard Life Insurance Company of New York, the duration of my claim(s) or 24 months, whichever occurs ﬁrst.

•For The Standard Beneﬁt Administrators, the duration of my claim(s) administered by The Standard Beneﬁt Administrators or 24 months, whichever occurs ﬁrst.

•For Absence Manager, 24 months.

•I acknowledge that I have read this authorization and the New Mexico notice on page 10. A photocopy or facsimile of this authorization is as valid as the original and will be provided to me upon request.

Name (please print)			Social Security No.
Signature of Claimant/Representative			Date

If signature is provided by legal representative (e.g., Attorney in Fact, guardian or conservator), please attach documentation of legal status.

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Standard Insurance Company

CTA Beneﬁts and Services

PO Box 2773 Portland OR 97208

Tel 800.522.0406 Fax 888.414.0390

Authorization to Obtain and Release Psychotherapy Notes

FOR RESIDENTS OF NEW MEXICO

The state of New Mexico requires Standard Insurance Company to provide you with the following information pursuant to its Domestic Abuse Insurance Protection Act.

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Get Si 3379 Cta PDF Form

Form Characteristics

Fact Name	Details
Form Purpose	The SI 3379 CTA form is used to apply for disability benefits through Standard Insurance Company.
Required Forms	Applicants must complete four forms: Employee’s Statement, Authorization to Obtain and Release Information, Attending Physician’s Statement, and Employer’s Statement.
Information Completeness	Every section must be filled in. If a question is not applicable, write “NA” to avoid processing delays.
Signature Requirement	Failure to sign or date the Employee’s Statement will result in its return for completion.
Claimant Responsibilities	The applicant is responsible for ensuring all forms are submitted correctly and on time.
Authorization Signatures	Separate signatures are needed for both the Authorization to Obtain Information and the Authorization to Release Psychotherapy Notes.
Physician Involvement	Part A of the Attending Physician’s Statement is completed by the claimant, whereas Part B is filled out by the physician.
Employer Statement	The Employer’s Statement must be completed and submitted directly by the employer on behalf of the employee.
Documentation	Applicants should attach any pertinent documents, like Social Security determinations, to support their claims.

Guidelines on Utilizing Si 3379 Cta

Completing the SI 3379 CTA form correctly is essential for a smooth claims process. Each section of the form needs careful attention, as any missing information can lead to delays. It’s important to ensure that all required forms are filled out completely and submitted in a timely manner.

Begin by filling out the Employee's Statement: Write your last name, first name, middle name, suffix, and social security number. Complete your address, phone number, patient number, birthdate, gender, height, and weight.
Provide information about your spouse or domestic partner, including their name, date of birth, and the number of dependent children.
Indicate if you have received a Certificate of Insurance or brochure from The Standard. If not, reach out to them for materials.
Navigate to the Employment section, listing your school district name, group policy number, job title, and job duties. Indicate if your disability is work-related, including the date of injury and if you filed a Workers’ Compensation claim.
Fill in the Sickness section, providing details about each illness that contributes to your inability to work. Note when you first noticed these illnesses and describe what you believe caused them.
In the Injury section, detail any injuries sustained, including the cause, date, time, and location of the injury.
If applicable, provide information about your Pregnancy, including your expected end of work date, expected delivery date, actual delivery date, and expected return to work date.
List all physicians consulted for your injury or illness in the Attending Physician section. Provide their names, specialties, phone numbers, addresses, and consultation dates.
If hospitalized, complete the Hospital section with the hospital name, address, and dates of hospitalization, along with the reasons for hospitalization.
In the History section, list all illnesses or injuries treated in the past five years, including treatment dates and physician details.
Complete the Deductible Income/Income from Other Sources sections by checking off the applicable boxes regarding benefits from sources like Social Security, Workers’ Compensation, and others. Provide details about the amounts, dates applied, and any relevant documentation.
Finally, certify your answers are complete and true by signing and dating the Acknowledgment section of the form.

Once you have completed all sections of the form, be sure to double-check for any missing information. Gather any necessary supporting documents, and submit everything as instructed. If you have questions or need assistance, don’t hesitate to reach out to the contact number provided on the form.

What You Should Know About This Form

What is the SI 3379 CTA form used for?

The SI 3379 CTA form is a Disability Benefits Claim Packet provided by Standard Insurance Company. It is used by employees to apply for disability benefits due to injury, sickness, or pregnancy. This form consists of several sections that gather necessary information from the claimant, their healthcare providers, and their employer to assess eligibility for benefits. Completing the form accurately and thoroughly is crucial to avoid delays in processing your claim.

What should I do if a section of the SI 3379 CTA form does not apply to me?

If a section of the SI 3379 CTA form does not apply to your situation, you must indicate this by writing "NA" in that space. This practice ensures that the claims processor knows you haven’t overlooked the question, thereby reducing the chance of your application being returned for incomplete information. It’s important to fill out every section clearly to facilitate a smooth claims process.

Who is responsible for submitting the required forms?

The responsibility of submitting the different forms lies with the claimant. You need to ensure that the Employee’s Statement is completed, along with obtaining the required signatures on the Authorization to Obtain and Release Information forms. Additionally, the Attending Physician’s Statement and Employer’s Statement must be filled out and submitted by the respective parties. Keeping track of these submissions is essential for a timely review of your claim.

What happens if I send in an incomplete form?

If you submit an incomplete form, it will likely be returned to you for completion. To avoid delays, it’s advisable to review the forms carefully before submission. Ensure all required fields are filled out, and all relevant documentation is attached. If you are unsure about any section, consider reaching out to Standard Insurance Company for clarification.

How can I check the status of my claim after I submit the SI 3379 CTA form?

You can check the status of your claim by contacting the Standard Insurance Company directly. Call their Disabilities Benefits Claims office at 800.522.0406 or send a fax to 888.414.0390. It's beneficial to have your claim number and personal information handy when you call to expedite the process. Patience may be required, as processing times can vary based on the complexity of the claim.

Common mistakes

When filling out the SI 3379 CTA form, many people make mistakes that can lead to delays or complications in their benefits application process. Here are nine common errors to avoid.

First, leaving sections blank is a frequent mistake. Every space on the form should be filled out completely. If a question does not apply, simply write “NA” in the relevant section. This shows that the question wasn't overlooked and prevents the form from being returned for completion.

Second, the failure to provide documentation can hinder processing. Applicants often forget to attach copies of important documents, such as Social Security determinations or applications for other benefits. It's crucial to include these documents as they aid in accurately calculating monthly benefits.

Third, not signing and dating the Employee’s Statement is another oversight. An unsigned or undated statement will be returned, causing further delay. Always double-check that you have provided all necessary signatures before submitting the form.

Fourth, people sometimes neglect to use the correct section for their specific situation. The form contains sections for sickness, injury, and pregnancy, and it's crucial to respond accordingly. Misplacing information can result in a lack of clarity about your claim.

Fifth, failing to specify all treating physicians can lead to incomplete information. If multiple doctors have treated you, ensure that each one fills out the necessary parts of the form. Your application may need comprehensive details from all healthcare providers involved in your treatment.

Sixth, some applicants inaccurately report their employment status or fail to provide job-related details. Your job duties and the nature of your disability must be clearly described. This information helps the insurer understand how your condition affects your ability to work.

Seventh, individuals frequently overlook the importance of submitting the Employer’s Statement. This form must be filled out by your employer and needs to be mailed directly to the insurer. Ensure you follow up with your employer to confirm it has been submitted.

Eighth, neglecting to report other income sources can create complications. If you receive income from Social Security, Workers' Compensation, or other sources, it’s crucial to disclose this. Include all relevant details to avoid potential issues with benefit calculations.

Ninth, applicants often forget to provide a history of previous treatments. Listing all illnesses or injuries treated in the past five years helps create a complete picture of your medical history. This information is vital for the processing of your claim.

By avoiding these common mistakes, applicants can enhance their chances of a smooth and efficient benefits application process. Attention to detail and thoroughness in filling out the SI 3379 CTA form make a significant difference.

Documents used along the form

The SI 3379 CTA form is a critical document utilized for filing claims for disability benefits with the Standard Insurance Company. It is accompanied by several other forms that also need to be completed as part of the application process. Below is a list of these additional forms, along with brief descriptions of their purpose.

Employee’s Statement: This form requires claimants to provide personal information, details about their employment, and a list of illnesses or injuries that hinder their ability to work. Accuracy is essential, as this information helps in the evaluation of the claim.
Authorization to Obtain and Release Information: Claimants must sign this form to allow the insurance company to gather necessary medical information from healthcare providers. This document is critical for the assessment of eligibility for benefits.
Attending Physician’s Statement: This is a two-part form. Part A must be filled out by the claimant, while Part B needs to be completed by their physician. It provides medical verification of the claimant's condition, which aids in the decision-making process.
Employer’s Statement: This form is to be filled out by the claimant's employer, detailing the claimant's job title, responsibilities, and the circumstances surrounding their absence from work. It helps establish the claimant's work history and the impact of their disability.
Hospital Records: While not specifically a form, hospital records may be required to support the claim. This documentation can include any relevant bills or discharge summaries relating to the condition being claimed.

Completing all required documents accurately and thoroughly is essential in expediting the claims process. If any questions arise during the process, assistance is readily available through the Standard Insurance Company.

Similar forms

When dealing with disability benefits and associated applications, several documents share similarities with the Si 3379 Cta form. Each serves a distinct purpose in ensuring a comprehensive evaluation of eligibility for benefits. Here are four documents that are similar:

Employee's Statement - This document is often included in disability claims, allowing the claimant to detail their condition, employment status, and any medical information. Like the Si 3379, it requires complete and accurate answers to facilitate timely processing.
Authorization to Obtain and Release Information - This form is crucial for granting permission to gather necessary medical and employment details. Similar to the Si 3379, it emphasizes the importance of consent in verifying eligibility for benefits.
Attending Physician's Statement - Much like the Si 3379, this document needs to be filled out by a medical professional. It includes important clinical information that evaluates the claimant's condition and supports the claim for benefits.
Employer's Statement - The Employer’s Statement, similar to the Si 3379, must be completed by the claimant’s employer. This document provides specific details about job duties and work-related circumstances surrounding the disability.

Dos and Don'ts

Do read the instructions carefully before starting to fill out the form.
Do fill in every space on the form to avoid any processing delays.
Do write "NA" in sections that do not apply to you.
Do sign and date your statements to ensure they are processed.
Do attach any relevant documentation, such as copies of Social Security or Workers’ Compensation determinations.
Don’t leave any questions unanswered, as the form may be returned for completion.
Don’t submit incomplete forms, as The Standard may return them for completion.
Don’t forget to obtain necessary signatures from your physician and employer.
Don’t assume your employer will automatically send in their part; follow up to ensure it is completed.

Misconceptions

There are several misconceptions about the SI 3379 CTA form, which can cause confusion during the disability benefits application process. Here are ten common misconceptions:

Only one form is required for application. Many believe that they can submit just one form. In reality, there are four forms that must be completed and submitted as part of the application package.
Completing the forms is optional. Some think filling out the forms is optional. However, every section must be completed to avoid delays. Incomplete forms may be returned.
Missing information is acceptable. It is a misconception that incomplete answers are tolerable. If a question does not apply, it is crucial to write “NA” so that it’s clear that the question wasn’t overlooked.
There is no need to attach additional documentation. Many applicants assume supporting documents are unnecessary. However, attaching copies of benefit determinations, such as Social Security or Workers' Compensation, is essential for accurate processing.
The applicant can sign any of the required forms. Some believe any signature suffices. Different forms require specific signatures, particularly the Employer's Statement, which must be completed by the employer.
All doctors can submit the Attending Physician’s Statement. It is often assumed that any physician’s statement is acceptable. In fact, only the attending physician's statement is valid and required.
Telephone communication is sufficient. Some applicants think that a simple phone inquiry can replace form submissions. However, written forms are mandatory to process claims officially.
The waiting period is not a concern during application. Some applicants may believe the waiting period for benefits starts once forms are submitted. In truth, benefits are typically retroactive, but the waiting period must still be acknowledged.
Email submissions are allowed. There is a misconception that forms can be submitted via email. However, forms must be mailed to the designated address provided in the instructions.
Assistance is not available for completion. Lastly, many individuals may think they have to complete the forms alone. Help is readily available through the Standard Insurance Company, which offers guidance on filling out the forms correctly.

Understanding these misconceptions can streamline the application process, helping applicants avoid common pitfalls and ensuring a smoother experience when applying for disability benefits.

Key takeaways

Filling out and using the SI 3379 CTA form can be straightforward when you follow these key points:

Every field must be filled out. If a question does not apply to you, write "NA" to indicate it was not overlooked.
Provide complete answers. If you need more space, use an additional sheet and attach it with your submission.
Sign and date your Employee’s Statement. An unsigned form will be returned for completion.
Include all relevant documents. This includes copies of any benefit determinations, like Social Security or Workers’ Compensation approvals.
Your physician must fill out Part B of the Attending Physician’s Statement. They should send it directly to The Standard.
Ensure your employer completes their section accurately. They are responsible for mailing their statement to The Standard.
If you have received treatment from multiple doctors, include a statement from each one regarding your condition.
Check with your group policy about how other benefits may affect your claim. This ensures accurate processing.
If you have applied for other benefits, always send copies of your application receipts and any determinations to The Standard.

Following these key takeaways can help minimize delays in the benefits processing and improve your experience with the claims process.

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