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American Fidelity (Michigan) > Short Term Disability Plan > Edit Plan
Please provide the following information for the
Short Term Disability
plan.
Plan Name:
Cost Structure:
Custom
Default
Broker Name:
Policy Number:
Original Plan Effective Date:
01/01/2003
Rate Guarantee Expiration Date:
mm
dd
yyyy
Plan Anniversary Date:
mm
dd
Billing Cut-off Day of the Month:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Retroactive Termination Limit:
30
60
90
120
150
180
Auxiliary Fields
(optional)
Field Name
Field Value
1.
Cigna Plan ID
2.
Plan ID
3.
Provider Code
4.
Geographic Code
5.
Classification
Required fields
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