Due to the changing of the Reliance Standard Disability benefits changing I thought I would take the opportunity to send out the old & new disability claim forms.
1st Form - Old Proof of Loss ($100) Claim Form - can be used before 10/1/2016 to claim wellness or illness/sickness
2nd Form - New Proof of Loss ($75) Claim Form - can be used after 9/30/2016 for illness/sickness or ER Visit
3rd Form - Short-Term Disability Claim Form - can be used after an employee has met waiting/elimination period.
If an ee is submitting an inpatient hospital claim and will be put on Short Term Disability, the participant will need to complete a Short Term Disability Claim form. Submit the Short Term form with the Attending Physician's Statement, an itemized billing/statement and Admission and Discharge paperwork from the hospital. In order to collect the hospitalization benefit
If an ee is wanting to claim an Inpatient Hospitalization Benefit without being on Short Term Disability they will need to complete the new Proof of Loss Claim and state on the form they were hospitalized as an inpatient on the form and submit it to Bay Bridge with a billing/statement along with Admission and Discharge paperwork from the hospital .
All forms regardless if it is a Proof of Loss or a Short Term Disability can be scanned to email@example.com or faxed to 512-275-9355 or mailed to Bay Bridge Administrators L.L.C., PO Box 161690, Austin, TX 78716. If at all possible it is better to scan the claim forms in, for some reason Bay Bridge seems to have issues with their faxes.
Forms are below: