Critical Illness Benefit Claim Form printable pdf download

Critical Illness

enefit Claim Form

merican General Life Insurance Company,

P O Box 1500, Nashville, TN 37202-1500

member of merican International Group, Inc. ( IG)

P RT

- To be completed by Insured

Insured/Patient must complete form 2118D to Obtain and Disclose information to expedite the claim process.

**SEE DEFINITION IN POLICY FOR THE CONDITION YOU SELECT**

____Invasive Cancer

____Heart ttack

____Kidney (Renal) Failure

____Stroke

Name of Insured ________________________________

____Coma

____Coronary rtery Bypass

____Major Organ Transplant

____Paralysis

Policy Number__________________________________

____UNOS dvance Benefit*

____Quadriplegia

Insured's Date of Birth ___________________________

(see endorsement)

____Paraplegia

____Severe Burn

____Hemiplegia

Claimant/Owner's Name, ddress, and Phone No.

____Loss of Sight, Speech or Hearing

____In Situ Cancer

Name ________________________________________

____Loss of Independent Living

____Dismemberment Rider

Street ________________________________________

____Health Screening (attach proof

(Form 183 required)

of type of screening)

____Return of Premium

City________________ State _____ Zip Code ________

____Medical Personnel HIV Benefit*

____Benefit Extension Rider

Phone No. ( ____ ) ___________________

*(Rider must be present)

Names and addresses of all physicians or practitioners and all hospitals or institutions by whom or in which you have been attended, treated

or examined during the last five years.

N MES

DDRESSES

D TES OF TTEND NCE

DISE SE OR CONDITION

___________________________ ___________________________ ___________________________ __________________________

---------- Payment of Policy Proceeds ----------

If your insurance benefit is $50,000 or more, you may elect to have the proceeds paid through a free, interest-bearing account called the Convenience Benefit

ccount

. (This option is not available for residents of laska, rkansas, Connecticut, Indiana, Kansas, Kentucky, Louisiana, Maryland, New Jersey, Rhode

Island and New York.)

• This is a draft account whereby you may draw down the insurance proceeds and interest by drafting drafts which are payable through State Street Bank and Trust

Company.

•

personal draft book will be mailed to you once your claim has been approved. You may access your account by writing a draft for $250.00 or more. If you wish, you

can write a single draft for the entire amount, including interest, to close your account. Your drafts are payable through State Street Bank and Trust Company. The

delivery of your draft book constitutes payment of your full benefit amount.

• There are no monthly service charges, per-draft charges or draft fees. Fees will be charged for the following special services: any draft presented for payment against

insufficient funds, any stop payment order, and any draft or statement copies. The charging bank reserves the right to change its fees at any time.

• Should your Convenience Benefit ccount balance drop below $10,000, the account will be automatically closed and a draft for the balance mailed to you, with

accrued interest on the 10

day of the following month.

• You will receive a monthly statement, showing all transactions, interest credited and the applicable rate(s) of interest for the period.

• Your Convenience Benefit ccount earns interest at a periodic interest rate determined by the company which is set after monitoring current short term rates and

other prevailing rates available in the marketplace.

• The interest rate is subject to periodic review and may be adjusted by the company. There is not a minimum interest rate credited to the account.

• Interest is compounded daily and credited to your account monthly. Interest may be taxable; please consult with your tax advisor regarding taxable interest amounts.

• To obtain the current interest rate for your account, please review your monthly statement or call 1-800-888-2402.

• Both your principal and any interest you earn are guaranteed by merican General Life Insurance Company ( merican General Life).

• The Convenience Benefit ccount is not insured by the Federal Deposit Insurance Corporation (FDIC). Its funds are guaranteed by the State Guaranty ssociations.

Please contact the National Organization of Life and Health Insurance Guaranty ssociations ( ) to learn more about coverage of your account.

•

ccount balances are the liability of merican General Life, and merican General Life reserves the right to reduce account balances for any payment made in error.

• Settlement options under any policy for which benefits are paid under a Convenience Benefit ccount are preserved until the entire Convenience Benefit ccount is

withdrawn or the balance drops below $10,000.00.

• If an initial life insurance benefit is less than $50,000, merican General Life will send you a check for the total benefit amount.

•

ny value remaining in your Convenience Benefit ccount may be transferred to the appropriate state authority as unclaimed property if no activity occurs in the

account within the time period specified by applicable state law.

If you have questions regarding the Convenience Benefit ccount, please call 1-800-888-2402 or write to merican General Life Insurance Company, 366S merican

General Center, Nashville, TN 37250. For all other claim related questions, please call 1-800-888-2452.

Select one of the following choices:

Please pay the insurance proceeds through the Convenience Benefit ccount

(Not available if you are a resident of laska, rkansas, Connecticut, Indiana,

Kansas, Kentucky, Louisiana, Maryland, New Jersey, Rhode Island and New York).

Please pay the insurance proceeds by check.

Signature

If you do not select one of the options above for payment, any proceeds

payable will be paid by company check.

Note: The signature on this Claimant’s Statement will be used as your signature

card for the Convenience Benefit ccount.

Date____________________________