Employer S Statement
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Employer’s Statement
LTD.2 (06/2017) This submission consists of two sections. The first section, parts A through D, relates to the employee’s employment status and should be completed by the LTDI Liaison Officer. The second section, parts E and F, relates to the employee’s specific job duties and should be completed by the employee’s immediate supervisor or manager. A current job description must be included with this submission. The completed Employer’s Statement is required before claim assessment can commence. Please ensure that it is completed and submitted to the LTDI Liaison Officer around the 20th day of the General Illness or WCB Supplement period.
A. Employer Information
1. Employing Ministry
2. LTDI Liaison Officer & Phone Number <
B. Employee Information
1. Mr. Mrs. Ms. Male Female
First Initial Last Name
Number & Street Address
P.O. Box
City Province Postal Code
Home Telephone Cell Number - - Number - -
2. Employee I.D.
Year Month Day 3. Date of Birth
C. Employment Information
Year Month Day 1. Commencement of Continuous Service
(include wage or temporary employment)
Year Month Day 2. Effective Date of Coverage
3. Type of a) Permanent Temporary b) Full Time Part Time Employment Superwage Contract (2850 hrs.) c) Hours of work per week
Year Month Day 4. First Day of Elimination Period (first day Employee was absent from work because of disability)
Year Month Day 5. LTDI Effective Date LTD.2 (06/2017) / Page 2 D. Earning and Benefit Information
1. Classification Job Code Is this position excluded from the Bargaining Unit? Yes No Basic bi-weekly salary at the end of the elimination period (do not include overtime, etc.): $
Year Month Day Effective Date of Salary Rate
2. Basic LTDI Bi-Weekly Benefit Amount $
3. Has the Employee applied for Yes Claim
Workers’ Compensation Benefits? No Number Has WCB approved the claim? Yes No Pending What is the weekly WCB benefit amount? $ Year Month Day When did WCB benefits start?
Year Month Day When did WCB benefits cease?
LTDI Liaison Officer
Date Signature
THE REMAINDER OF THIS SUBMISSION SHOULD BE COMPLETED BY THE EMPLOYEE’S IMMEDIATE SUPERVISOR OR MANAGER.
E. Disability/Rehabilitation
1. Worksite Address
Year Month Day 2. Did the disability affect the employee’s work? Yes
If so, from what date? No
3. Did performance on the job change prior to the employee going off work? If so, please explain.
Year Month Day 4. Were any changes made in the employee’s Yes
job as a result of the disability? No If yes, please explain.
Year Month Day 5. Did the employee attend Yes No Pending a Medical Board?
LTD.2 (06/2017) / Page 3 F. Job Information
1. Employee’s working title as of last day worked
Year Month 2. How long has the employee performed these job duties?
3. Please specify each of the major duties in this job and estimate the percentage of time each one takes on a monthly basis. Please use the back of this form if more space is required. A copy of the current job description must be included.
CURRENT DUTIES Percentage of Time (must total 100%) [You can add or delete extra rows.] % % % % % %
EQUIPMENT REQUIRED Approx. (computer-please specify applications/programs, fax, forklift, etc) Percentage of Time [You can add or delete extra rows.] % % % %
WORK ENVIRONMENT Approx. Percentage of Time Outside % Office % Home % In a damp or humid environment % In extremes of cold or heat % In and around odors/fumes % Use of chemicals (please list): (You can add or delete extra rows.) % % %
Occasionally Frequently Constantly ACTIVITY N/A (0-33%) (34-66%) (67-100%) Sitting Standing Walking Climbing (stairs, ladders, etc.) Driving Lifting 100 lbs/45 kg
LTD.2 (06/2017) / Page 4 Occasionally Frequently Constantly ACTIVITY N/A (0-33%) (34-66%) (67-100%) Sitting Standing 50 lbs/22.7 kg 20 lbs/9.1 kg 10 lbs/4.5 kg Less than 10 lbs/4.5 kg Mobility Reaching above shoulder height Reaching at shoulder height Reaching below shoulder Bending or crouching Kneeling or crawling Keyboarding/Data Entry
Does the employee have the flexibility to sit, stand or change Yes No positions during the course of a normal work day?
4. When completing the following section please check the space that most accurately describes the percentage of time the employee is required to perform the following tasks during the course of a normal work day.
Category N/A Occasionally Frequently Constantly (0-33%) (34-66%) (67-100%) Critical thinking The extent tasks require attention to detail Multi-tasking Performance / monitoring more than one task at a time, and judging when tasks require attention Exposure to distracting stimuli Visual, auditory or other sensory stimuli Self-Supervision Extent of self supervision required Supervision of others Extent of work direction and/or supervision provided to other workers Time Management Extent work tasks are expected to be completed within a given time, or the extent a fast pace is required because of the work nature or volume of work Team Work Effective partnership, team projects, shared job duties, etc. Exposure to emotional situations Emotionally stressful circumstances or interaction with distressed individuals Exposure to confrontational situations Potential direct confrontation by individuals or confrontational situations requiring action Exposure to safety risks Extent of liability or risk if the employee does not exercise appropriate judgment or attention Verbal Communication Ability to clearly comprehend and express ideas and information
LTD.2 (06/2017) / Page 5 Category N/A Occasionally Frequently Constantly (0-33%) (34-66%) (67-100%) Critical Decision Making Ability to reach an opinion, judgment, or position after consideration Reading Literacy Ability to comprehend written text Written Literacy Requirement to independently compose written text Numeric Literacy Requirement to process and analyze numerical information; including electronic calculation Computer Literacy Ability to use computer technology Memory Retrieval and recall of information on demand
5. Please provide any additional information that you believe should be considered in assessing this employee’s claim and planning the return to work (e.g., position changes or restructuring).
This Employer section was completed by:
Signature Name (please print) and Title
- - - - Date Phone Number Fax Number
E-mail Address
The information provided on this form will be used for the purpose of administering Long Term Disability Income benefits. The collection and use of personal information is in accordance with the Public Service Act and the Freedom of Information and Protection of Privacy Act. If you have any questions about this, please contact the LTDI Liaison Officer.
LTD.2 (06/2017) / Page 6