Form A - Applicant Information For Comprehensive Protection Plan Page 3
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4Liberty Life Assurance Company of
Boston
Group Benefits Disability Claims
P.O. Box 7206
London, KY 40742-7206
Phone: 800-210-0268
Fax: 603-334-0401
Authorization to Obtain and Release Information
(Excluding Psychotherapy notes)
EMPLOYEE NAME:
CLAIM NO:
EMPLOYER/SPONSOR/CUSTOMER NAME:
RETURN TO: Dover Claims
I authorize any licensed physician, health care professionals, hospital, clinic, pharmacy, other medical or medically related
facility, rehabilitation professional; vocational evaluator; government agency including the Social Security Administration and
Veterans Administration, insurance or reinsurance company, credit or consumer reporting agency, financial/educational
institutions and any current or former employer to release any and all of the following information to the particular Company in
the Liberty Mutual Insurance of companies to which I am submitting claim, or to its legal representative, or to the Plan Sponsor
(if Self-Insured Plan), or to persons or other organizations providing claims management services:
1. Medical information with respect to any physical or mental condition and/or treatment of me, including confidential
information regarding AIDS/HIV infection, communicable diseases, alcohol and substance abuse, and mental health (excluding
psychotherapy notes).
2. Information with respect to: job duties, earnings, employment applications, personnel records, and other work
related information; records and information related to any insurance coverage and claims filed; credit information
including, but not limited to, credit reports and credit applications; other financial information including bank
records; complete copies of Federal and State tax returns; including attachments; and academic transcripts.
3. Information concerning Social Security benefits, including, but not limited to, monthly benefit amounts, monthly
Supplemental Security Income payment amounts, entitlement dates, information from my Fact Query, and any
benefits to which my dependents may be eligible under my record.
I understand the Company or Plan Sponsor will use the information obtained under this Authorization or directly from
me to determine eligibility for insurance benefits, which may include assessing ongoing treatment. Any information
obtained will not be released to any person or organizations EXCEPT to the Plan Sponsor, reinsuring companies,
other companies in the Liberty Mutual Insurance of companies to which I am submitting a claim, Employee Assistance
Programs (EAP) or other disease management or assistance programs providing services to the Plan Sponsor and/or
to the Company, persons or other organizations providing claims management and claim advisory services to the Plan
Sponsor and/or to the Company, the Group Policyholder and its agents/vendors for purposes of auditing the Company’s
administration of claims under the policy and/or assessing statistical claim data related to its benefit programs, persons
or organizations providing medical treatment or services in connection with my claim, or as may be otherwise permitted
or required by law. I also understand that, to the extent reasonably necessary, information obtained may be released
to other insurance companies or insurance support organizations to detect or prevent criminal activity, fraud, material
misrepresentation, or material non-disclosure in connection with insurance transactions.
I understand that this authorization is valid for two years from the date appearing below with my signature. I understand that I
have a right to request and receive a copy of this authorization. I understand that I have the right to revoke this Authorization at
any time by notifying the Plan Sponsor and/or the Company in the Liberty Mutual Insurance of companies for which I submit a
claim. If I do not sign this authorization or if I alter or revoke it, Liberty may not be able to evaluate my claim(s), which may lead
to my claim(s) being denied. I understand that revocation will not apply to any information that is requested prior to Liberty
receiving notice of revocation.
Claimant Name ( Print)
Date of Birth
Claimant Signature
Date
_______________________________________________
Claim Number:
DP432 (rev 06/12)
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