Group Benefit Services Application For Accidental Death Benefits - Mutual Of Omaha Insurance Company Page 4
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4Statement of Attending
Physician1. ______________________________________________________________________________
1. Name of deceased __________________________________________________________________________________________
2. Where and when did you first attend deceased? _________________________________________________________________
3. Was deceased hospitalized? _______________ Name of hospital ___________________________________________________
4. Describe deceased’s condition on your first visit _________________________________________________________________
___________________________________________________________________________________________________________
5. Were there any symptoms or signs of disease? Yes ______ No ______ If “Yes,” describe ______________________________
___________________________________________________________________________________________________________
6. Give date of accident ________________________________________________________________________________________
7. Were there any visible contusions or wounds on the body of deceased? _____________________________________________
___________________________________________________________________________________________________________
8. What was the nature and extent of the injuries? __________________________________________________________________
___________________________________________________________________________________________________________
9. What was the date of death? __________________________________________________________________________________
10. What was the primary cause of death? _________________________________________________________________________
___________________________________________________________________________________________________________
11. Did any disease or cause, other than the injury referred to, complicate or contribute to the cause of death? _______________
__________________________________________________________________________________________________________
If so, what? ________________________________________________________________________________________________
12. Was the injury described above, independently of all other causes, sufficient to cause death? __________________________
__________________________________________________________________________________________________________
13. If a postmortem examination was made, what were the findings as to cause of death? ________________________________
__________________________________________________________________________________________________________
14. Give names and addresses of other physicians or surgeons, if any, who attended deceased after the injury _______________
__________________________________________________________________________________________________________
Date ______________________
_________________________________________________________________________
Attending Physician Sign Here
Street Address ___________________________ City ____________________ State __________________ ZIP Code ________________
Statement of Master Policyholder or Group Administrator
1. Full name
Soc. Sec.
Eff. date of
of deceased _______________________________ No. _______________________________ insurance _________________
Name of
Soc. Sec.
Eff. date of
Employee _________________________________ No. _______________________________ insurance _________________
2. Date employment began ____________________________ Occupation at time of death ______________________________
3. Date of last active work _____________________________ If retired, date retired ____________________________________
4. Premium for the above deceased has been paid through _________________________________________________________
5. If date deceased last worked was more than 31 days prior to death, was deceased:
totally disabled?
on leave of absence?
on temporary layoff?
6. If benefits are based on earnings, give amount of monthly earnings _______________________________________________
(Note: We may require supporting documentation of earnings and paid premiums to process the claim.)
7. If your plan has more than one class, show class deceased was covered under ______________________________________
8. Name of beneficiary shown on your records _________________________________________ Relationship ______________
Note: Attach Original Enrollment Record Plus any beneficiary changes.
9. Amount of Benefit: AD&D $ ____________
Felonious Assault $ ____________
Vol AD&D $ ____________
Common Carrier $ ____________
Seat Belt $ ____________
Airbag $ ____________
Repatriation (attach bill) $ ____________
Repatriation: miles from residence ____________
Master Policy No. ____________________________ _______________________________________________________________
Name of Policyholder
Date _______________________________________ By ___________________________________________________________
Signature and Title
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