Employees covered by a MetLife-insured New Jersey private temporary disability plan file JY5334 to claim weekly accident and sickness benefits. Page 1 holds the employee's and employer's statements; page 2 is the Attending Physician's Statement, where the physician describes the sickness or injury, any pregnancy and complications, surgery, treatment dates, and the period of continuous disability and return-to-work date.
The attending physician completes the Attending Physician's Statement on page 2. The employee completes and signs the top of page 1, authorizing the physician to release information, and the employer completes the rest of page 1 with coverage, last day worked, salary continuation and workers' compensation details.
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New Jersey Employee Statement of Claim for Accident and Sickness Weekly Benefits (Attending Physician's Statement)
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The attending physician completes page 2, the Attending Physician's Statement, and signs it with printed name, address and phone. The employee and employer complete page 1, and the employee's signature authorizes the physician to release information requested for the claim.
The date from which the patient has been continuously disabled and unable to work, the date they were or will be able to return to work, the dates of office, home and hospital treatment, and the date of any surgery. The employee separately reports the date first disabled and any hospital admission and discharge.
Yes. The physician section asks whether the condition is due to pregnancy, the expected delivery date, the date and manner if the pregnancy has ended, and whether the patient had a totally disabling complication of pregnancy, with the full diagnosis or details of that complication.