Fillable Initial Credit/closed End Monthly Outstanding Balance Disability Claim Form (Page 2 of 4) in pdf

A. CREDITOR’S INFORMATION

(ATTACH A PHOTOCOPY OF POLICY/CERTIFICATE)

PLEASE PRINT

POLICY/CERTIFICATE # (INCLUDE PREFIX)

DATE OF ISSUE

TERM IN MONTHS

AGENT CODE

BRANCH NO.

CLAIM NUMBER

ACCOUNT # / LOAN #

DUE DATE

POLICY EXPIRES

A&H COVERAGE

FORM # OF POLICY/CERTIFICATE

Retro ______________ Days

WERE HEALTH QUESTIONS USED

(IF YES, ATTACH A COPY OF

PREVIOUS LOAN #

PREVIOUS POLICY # / CERTIFICATE #

WAS THIS LOAN REFINANCED

COMPLETED APPLICATION.)

Yes

DATE OF ISSUE

EXPIRATION DATE

PREVIOUS MONTHLY BENEFIT

MONTHLY BENEFIT

PREVIOUS TERM

NAME OF DEALER OR BRANCH WHERE INSURANCE WAS PURCHASED

FIRST BENEFICIARY/CREDITOR

TELEPHONE NUMBER

(

)

STREET ADDRESS

CITY

STATE

ZIP CODE

NAME OF PERSON COMPLETING THIS SECTION (PLEASE PRINT)

SIGNATURE

DATE

B. CLAIMANT’S STATEMENT FOR ACCIDENT OR SICKNESS CLAIM

PLEASE PRINT

NAME OF FINANCIAL INSTITUTION (WHERE PAYMENT IS TO BE MADE)

CLAIMANT’S EMAIL ADDRESS (IF AVAILABLE)

FULL NAME OF CLAIMANT

DATE OF BIRTH

STREET ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NUMBER

(

)

WHAT IS YOUR USUAL OCCUPATION

DESCRIBE YOUR USUAL JOB DUTIES

WERE YOU EMPLOYED WHEN DISABILITY BEGAN

IF YES, LAST DATE WORKED

GIVE EXACT REASON FOR YOUR UNEMPLOYMENT

Yes

ARE YOU RETIRED

IF YES, DATE RETIRED

REASON FOR RETIREMENT

Yes

NAME, ADDRESS AND PHONE NUMBER OF THE EMPLOYER YOU WERE WORKING FOR WHEN YOUR DISABILITY BEGAN (IF UNEMPLOYED WHEN DISABILITY BEGAN, STATE NAME, ADDRESS

AND PHONE NUMBER OF LAST EMPLOYER)

DISABILITY CAUSED BY

DATE ACCIDENT HAPPENED OR DATE

DESCRIBE YOUR SICKNESS OR INJURY

SICKNESS BEGAN

Accident

Sickness

ON WHAT DATE WERE YOU FIRST TREATED BY A PHYSICIAN FOR THIS

GIVE NAME OF PHYSICIAN

TELEPHONE NUMBER

(

)

SICKNESS OR INJURY

LIST ALL DOCTORS, CLINICS, AND HOSPITALS WHICH TREATED YOU IN THE PAST FIVE YEARS, FOR ANY INJURY, ILLNESS OR GENERAL CHECK-UPS -- INCLUDE COMPLETE ADDRESS AND

PHONE NUMBER (ATTACH A SEPARATE LIST IF ADDITIONAL SPACE IS NEEDED)

ARE YOU NOW RECEIVING OR HAVE YOU APPLIED FOR: (IF YES, ATTACH A COPY OF THE AWARD LETTER)

DATE OF ENTITLEMENT

Social Security Disability

Yes

Other Disability Benefits

____________________________________

GIVE FIRST DATE YOU DID NOT WORK BECAUSE OF THIS

DATE YOU RETURNED TO WORK PART-TIME

DATE YOU RETURNED TO WORK FULL-TIME

NUMBER OF HOURS PER DAY

SICKNESS OR INJURY

IF YOU HAVE RETURNED TO WORK PART-TIME, DESCRIBE THE DUTIES YOU ARE ABLE TO PERFORM

I AUTHORIZE any employer, physician, hospital, clinic, other medical or medically related facility, the Medical Information Bureau, Inc., consumer reporting agency,

insurance or reinsuring company, insurer, law enforcement agency, fire department, Social Security Administration, Internal Revenue Service, or other

organization, or person having any records, data or information concerning this claim to furnish such record, data or information to the insurance company issuing

my policy as requested. I understand that in executing this authorization, I waive the right for such information to be privileged as it pertains to the processing or

investigation of my claim(s). A photocopy of this authorization shall be considered as effective and valid as the original.

I understand and acknowledge that this authorization extends to all or any part of the records being requested, which may include treatment for physical and mental

illness, alcohol/drug abuse, and/or HIV/AIDS test results or diagnosis and treatment. I expressly consent to the release of information as designated above.

The above information is true and correct. If in fact the furnished information is false thereby inducing payment of claim and the insurance company issuing my

policy determines that the incorrect information constitutes an aiding and abetting the filing of a fraudulent claim, the insurance company issuing my policy may

furnish the above information to the appropriate state authorities to be used in its discretion as the basis for action authorized under applicable state law. In addition,

I agree any statements made on this or any other form found to be false, shall give the insurance company issuing my policy the right to void my policy.

I, or my authorized representative, have the right to receive a copy of this authorization.

This authorization shall be valid for the duration of the claim.

WARNING: Any person who knowingly and with intent to defraud any insurance company or other person

files an application for insurance or statement of claims containing any materially false information or

conceals, for the purposes of misleading, information concerning any fact material thereto, commits a

fraudulent insurance act, which is a crime, and may subject such person to criminal and substantial civil

penalties. For other Fraud Statements see Page 3.

CLAIMANT’S SIGNATURE

SOCIAL SECURITY NUMBER

DATE

C. EMPLOYER’S STATEMENT

(MUST BE FULLY COMPLETED)