Caterpillar Inc.

Employee Name: ________________________________

Application for Leave of Absence Employee ID: ________________________________
(Short Term Disability, Parental Leave, FML)
Return all pages of this form to any of the following:
1) Email: LOA@cat.com
2) FAX: (309) 285-8798
__________________________________________________________________________________________

All 3 pages need to be completed in its entirety for your claim to be reviewed. Page 3 must be completed by your physician only. It is your
responsibility to have the physician’s office complete their section and you are responsible for any fees associated with the completion of this
application. You have 30 days from your first day absent from work to submit this application to the above email/fax. Claims received more than 30
days after the first day of eligibility may be denied.

TO BE COMPLETED BY THE EMPLOYEE

(Please answer all questions)

1. Employee name (print)__________________________________________DOB: _____________________

Employee ID:_____________________
2. Email: _________________________________________Phone No: _______________________________

3. First date missing work due to this absence ______ /_______ /_______
4. If childbirth, estimated/Actual Date of Delivery ______ /_______ /_______
5. Describe the reason for missing work:___________________________________________________________
__________________________________________________________________________________________
Yes No N/A Date
6. Is this due to a car accident? ☐ ☐ ____ /_____ /______
7. Is this absence related to a work-related incident? ☐ ☐ ☐ ____ /_____ /______
8. Are you receiving Social Security Benefits ☐ ☐
9. Are you currently working for any employer ☐ ☐
other than Caterpillar or are you self-employed?
10. Do you intend to continue working for another employer ☐ ☐
or be self-employed while you are on leave from Caterpillar?

EMPLOYEE AUTHORIZATION
You must read, sign and date both Authorization sections of this form to file a claim for benefits.

I hereby authorize the release of any information required to act on this or any prior claim for disability benefits. I also understand that any information
relevant to my potential eligibility for Social Security benefits may be disclosed to Integrated Benefit, Inc. (IBI) or other similar vendors. I hereby permit a
photographic or other facsimile reproduction of this authorization to be used in place of the original. I consent to being contacted by personal phone
and/or email regarding my leave benefits. At anytime I can choose to change my preferred method of communication.

All of my information is accurate, and I am responsible for updating any and all personal information in Workday. I hereby certify that the answers I have
made to the foregoing questions are both complete and true to the best of my knowledge and belief. I understand to contact my Disability Benefit
Representative if I intend to work for another employer while out on leave.

If I receive any wages or benefits to which I am not entitled by reason by reason of filing this claim for disability benefit, I hereby authorize the company to
deduct the amount of such overpayments from any wages, salary or other payments due to me, including any benefit plan payments. I agree to sign any
consent or authorization necessary for the company to make such deduction.

Employee Signature: ______________________________________________ Date: ______________

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Caterpillar: Confidential Green
 Caterpillar Inc. Employee Name: ________________________________
Application for Leave of Absence Employee ID: ________________________________
(Short Term Disability, Parental Leave, FML)
Return all pages of this form to any of the following:
1) Email: LOA@cat.com
2) FAX: (309) 285-8798
__________________________________________________________________________________________

HIPAA AUTHORIZATION

Please note that in order to process your claim for disability benefits and to administer your disability benefits if your claim is approved, Caterpillar, as Administrator of
the Disability Benefit Plan, needs certain health information that may be protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). By
executing the HIPAA Authorization, you are authorizing those entities that are subject to HIPAA’s privacy and security standards to release your health information in
connection to your claim for disability benefits. Please be advised that the Disability Plan is exempt from HIPAA.

I understand that this authorization has been carefully and specifically drafted to permit disclosure of my protected health information consistent with the requirements
of HIPAA. It is my intent that any entity disclosing information pursuant to this authorization recognize the authorization as satisfying the requirements of HIPAA.

For purposes of i) determining my eligibility for disability benefits or ii) the administration of Caterpillar’s disability benefit plans, I authorize any: 1) physician, 2) non-
physician medical/treating practitioner, 3) hospital, 4) clinic, 5) medical related facility, 6) person or entity deemed to be a covered entity as defined by HIPAA, 7)
insurer, 8) government agency, or 9) benefit plan administrator to disclose to Caterpillar Inc in its capacity as administrator of its disability benefit plans any and all
information about my health or medical care which is the basis of my disability claim.

This authorization specifically includes my permission to disclose medical information, records, test results, and data on: medical care or surgery, psychiatric or
psychological medical records, but not psychotherapy notes; and records relating to alcohol or drug abuse. Information concerning mental illness, HIV, AIDS, HIV
related illnesses and sexually transmitted diseases or other serious communicable illnesses which might be controlled by various laws and regulations. I consent to
disclosure of such information, but only in accordance with laws and regulations as they apply to me.

I understand the following statements about my rights:

• I may revoke this authorization at any time by submitting my request in writing to the Disability Supervisor, Caterpillar Inc. at 100 NE Adams
Street, Peoria, IL 61629 or by informing my healthcare provider or health plan.

• The revocation of this authorization will not have any effect on any actions that any entity took before it received the revocation.

• If I do not revoke this authorization, it will be valid from the date that I sign this authorization and will last for the duration of my claim for
disability benefits.

• If I ask, I may see a copy of the information provided to Caterpillar Inc. pursuant to this authorization.

• I am not required to sign this authorization to receive health care benefits from my group health plan. However, because this information will
be used to make a determination as to whether I am eligible to receive disability benefits, I am required to sign this authorization to receive
disability benefits.

• The information that is used or disclosed pursuant to this authorization may be re-disclosed by the receiving entity. If information is re-
disclosed as permitted by this authorization, it may no longer be protected by applicable federal privacy law.

I understand that I have a right to receive a copy of this authorization upon request. I agree that a copy of this authorization may be used in place of the original.

Employee Signature: _____________________________________________ Date: ______________

Print Name _____________________________________________________

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Caterpillar: Confidential Green
 Caterpillar Inc. Employee Name: ________________________________
Application for Leave of Absence Employee ID: ________________________________
(Short Term Disability, Parental Leave, FML)
Return all pages of this form to any of the following:
1) Email: LOA@cat.com
2) FAX: (309) 285-8798
__________________________________________________________________________________________

TO BE COMPLETED BY THE TREATING PHYSICIAN

(Please answer all questions)
1. Patient Name: _______________________________________Patient DOB:_____________________
2. Primary Diagnosis: ___________________________________ Primary Diagnosis Code: ______________
3. Secondary Diagnosis: _________________________________Secondary Diagnosis Code: ____________
4. Objective Findings: _____________________________________________________________________
5. Functional Limitations (reasons unable to work):______________________________________________
6. Planned course of treatment: ____________________________________________________________

Short Term Disability

Yes No Date
7. If childbirth, estimated/actual date of delivery ☐ ☐ ______ /_______ /_______
8. Patient Hospitalized ☐ ☐ ____ /____ /____ to ____ /_____ /_____
9. Surgery Performed ☐ ☐ ____ /_____ /_____
Name of procedure: ____________________________________________ ☐ Outpatient ☐ Inpatient
10. In your opinion, is this disability the result ☐ ☐
of an injury at work or occupational disease?
11. Last seen by Physician for this diagnosis ____ /_____ /_____
12. Period of Incapacity ____ /____ /____ to ____ /_____ /_____
13. Estimated to return to work (day following incapacity period) ____ /_____ /_____

Family Medical Leave Intermittent Timeframe: _____ /____ /____ to ____ /_____ /_____
Yes No
14. Will there be continuing treatment other than OTC medication? ☐ ☐
15. Will the patient have follow-up appointments or ☐ ☐
additional treatments outside of the incapacity dates?
_______ times per ☐ day ☐ month ☐ year and are likely to last ______ ☐ hours ☐ days per occurrence.
16. Will the patient have flare ups outside of the incapacity dates? ☐ ☐
_____ times per ☐ day ☐ month ☐ year and are likely to last approximately # of ______ ☐ hours ☐ days per episode.
17. Are there any restrictions once returned to work? ☐ ☐
18. Describe Restrictions once returned to work including range of dates: ____ /____ /____to ____ /____ /____
_____________________________________________________________________________________________________________________
Additional Comments: ___________________________________________________________________________________________

I hereby certify that the answers I have made to the foregoing questions are both complete and true to the best of my knowledge and
belief.

_____________________________________________ ________________________
Physician’s Signature (REQUIRED) Date (mm/dd/yyyy)

____________________________________________ ___________________________________
Physician’s Name (please print) Degree and Specialty

___________________________________________________________________________________________________________
Street No. Address City State Zip Code

___________________________ _________________________
Phone Number Fax Number

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