CLEAR

CIGNA Group Insurance

. .
Life Accident Disability
Life Insurance Company of North America
Connecticut General Life Insurance Company
CIGNA Life Insurance Company of New York

UTC Job Requirements

(To be completed by the employer)

Please complete the following items based on the employee’s job title.

Employee’s Name: Date of Birth:

Please describe the job duties, tasks performed, type of industry, materials / tools / equipment used, products
made, services rendered, etc.:

In an 8-hour workday, the employee is required to perform the following:

Continuously Frequently Occasionally
(67-100%) (34-66%) (1-33%) Not required
(5.5 + hrs) (2.5 - 5.5 hrs) (<2.5 hrs) for this job

Lifting: 10 lbs.
11-20 lbs.
21-50 lbs.
51-100 lbs.

100+ lbs.
Carrying: 10 lbs.

11-20 lbs.
21-50 lbs.
51-100 lbs.
100+ lbs.
Pushing: (Max. Wt.: ____________ )
Pulling: (Max. Wt.: ____________ )
Sitting:
Standing:

Walking:
Climbing: Regular Stairs

Regular Ladders
595958 09/2005
 Continuously Frequently Occasionally
(67-100%) (34-66%) (1-33%) Not required
(5.5 + hrs) (2.5 - 5.5 hrs) (<2.5 hrs) for this job

Balancing:

Stooping:

Kneeling:

Crouching:

Crawling:

Seeing:

Hearing:

Smell/Taste:

Reaching: Overhead
Desk Level

Below waist

Fine Manipulation: Right

Left

Simple Grasp: Right

Left

Firm Grasp: Right

Left
Environmental Conditions:
Exposure to extremes in heat
Exposure to extremes in cold

Exposure to wet / humid conditions

Exposure to vibration

Exposure to odors / fumes / particles

Required to work extended shifts / overtime:

Use lower extremities for foot controls:

Please include any physical requirements of the job not listed above:
 Temperaments and Aptitudes Yes No

Directing, Controlling, Planning: Required to accept responsibility for control, direction, or

planning of an activity.
Performing Repetitive Work: Required to perform repetitive or continuous activity according
to set procedures.
Influencing People: Required to influence people in their opinions, attitudes, or judgements
about ideas or things.
Performing a Variety of Duties : Required to perform a variety of duties, often from one task to
another without loss of efficiency or composure.
Expressing Personal Feelings: Required to interpret feelings, ideas, or facts in terms of
personal viewpoint.
Working in Alone or Isolation: Required to be without face-to-face contact for extended
periods of time.
Performing Under Stress: Required to perform under stress when confronted with emergencies
or unusual situations.
Attaining Precise Limits/Tolerances: Required to perform with demands of precise attainment
of set limits, tolerances, or standards.
Following Specific Instructions: Required to perform without room for independent action or
judgement.
Dealing with People: Required to deal with people beyond giving and receiving instruction
such as working as a member of a team or committee.
Making Judgements and Decisions: Required to make generalizations, judgements, or
decisions based on subjective or objective criteria such as with the five senses or factual data.

Please include any other work temperaments or aptitudes not listed above:

Supervisor’s Name Phone #

Supervisor’s Department Date

Thank you for your time.

Please return this form as soon as possible.