United of Omaha uses this seven-page claim when an employee becomes disabled and asks to have group life insurance premiums waived. The employer completes Part I, the employee Part II, and the attending physician Part III: primary diagnosis with code, treatment dates, symptoms, restrictions and limitations, prognosis, maximum medical improvement and capacity in an eight-hour workday.
The employer or plan administrator completes Part I and the employee completes Part II and the authorization. The attending physician completes and signs Part III, the Attending Physician's Statement.
Download the current version from the source each time; forms change without notice.
Waiver of Premium Claim Form – Part III Attending Physician's Statement
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Part I is completed by the employer or plan administrator, Part II by the employee or member, and Part III, the Attending Physician's Statement, by the attending physician. The employee also signs the authorization to release personal information.
Yes. Mutual of Omaha posts a Spanish version alongside the English form. Either version is returned to United of Omaha's Group Life Claims with the employee's enrollment form and any beneficiary changes.