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Disability Claim

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disability-claim.pdf

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JSON

claim_number

DIS-2024-678901

claim_date

2024-03-10

policy_number

STD-2024-234567

group_policy_number

GP-CORP-5000

claimant_name

Richard Brown

claimant_dob

1975-09-18

claimant_ssn_last4

5678

claimant_address

890 Recovery Lane, Austin, TX 78701

claimant_phone

(512) 555-0345

employer_name

Texas Manufacturing Inc.

occupation

Machine Operator

annual_salary

65000

date_disability_began

2024-02-28

last_day_worked

2024-02-27

disability_type

Short-Term

diagnosis

Lumbar disc herniation

icd_10_code

M51.16

treating_physician

Dr. Maria Garcia, MD

physician_phone

(512) 555-0456

restrictions

No lifting over 10 lbs, No prolonged standing, Limited bending

expected_return_date

2024-05-01

other_income_sources

None

{ "claim_number": "DIS-2024-678901", "claim_date": "2024-03-10", "policy_number": "STD-2024-234567", "group_policy_number": "GP-CORP-5000", "claimant_name": "Richard Brown", "claimant_dob": "1975-09-18", "claimant_ssn_last4": "5678", "claimant_address": "890 Recovery Lane, Austin, TX 78701", "claimant_phone": "(512) 555-0345", "employer_name": "Texas Manufacturing Inc.", "occupation": "Machine Operator", "annual_salary": 65000, "date_disability_began": "2024-02-28", "last_day_worked": "2024-02-27", "disability_type": "Short-Term", "diagnosis": "Lumbar disc herniation", "icd_10_code": "M51.16", "treating_physician": "Dr. Maria Garcia, MD", "physician_phone": "(512) 555-0456", "restrictions": [ "No lifting over 10 lbs", "No prolonged standing", "Limited bending"], "expected_return_date": "2024-05-01", "other_income_sources": "None"}