Form Teb-Adbltchome-072413 - Accelerated Death Benefit For Long Term Care Claim Form

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Accelerated Death Benefit
Transamerica Life Insurance Company
for Long Term Care
Monumental Life Insurance Company
P.O. Box 8043
(Home Health)
Little Rock, AR 72203-8043
Claim Form
Phone: 800-251-7254 (7:00 a.m. – 5:00 p.m. CST)
Fax: 866-586-6528
Employer’s/Business Entity’s Statement
1. Name of Employee/Insured Person
2. Social Security No.
3. Date of Birth
4. Phone No.
5. Group No.
6. Occupation
7. Employee’s/Insured Person’s Street Address
8. City
9. State
10. Zip Code
11. Employer/Business Entity
12. Employer/Business Entity Phone No.
13. Duties
14. Employer’s/Business Entity’s Street Address
15. City
16. State
17. Zip Code
Signed in (City/State)
This
Day of (Month/Year)
.
Name of Company
Signature
Official Position
Claimant’s Statement
 Home Health Care  Adult Day Care  Assisted Living  Other _______________________
1. Policyholder
2. Policyholder’s Social Security No.
3. Policy No.
4. Patient’s Name
5. Patient’s Social Security No.
6. Phone No.
7. Street Address
8. City
9. State
10. Zip Code
11. Type of Residence:  Home  Apartment  Retirement Community  Other _______________________
12. Describe condition for which claim is being made
13. Name of Attending Physician
14. Phone No.
15. Street Address
16. City
17. State
18. Zip Code
19. Name of Hospital
20. Date Admitted
21. Date Discharged
22. Street Address
23. City
24. State
25. Zip Code
Name, address and telephone number of person assisting with claim (if any)
26. Name
27. Relationship
28. Phone No.
29. Street Address
30. City
31. State
32. Zip Code
Attach a copy of Legal Instrument. Check One:
 Power of Attorney  Guardianship
Patient or Personal Representative’s Signature ________________________________________________
Date _______________________
TEB-ADBLTCHome-072413
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