Death Claim Form - TSCRA Insurance

Death Claim Form
Group Life and Accidental Death Insurance
Return to Dearborn National at:
Attention: Claims Department
P.O. Box 655403
Dallas, Texas 75265-5403
Phone Number: (800) 778-2281
Fax: (972) 996-9361
INSTRUCTIONS
Upon the death of an insured employee, plan member or insured dependent, the employer/administrator must
complete the claim form as indicated and send attachments mentioned below. Be advised that further documentation
might be necessary in the future to complete the claim process.
Please submit the following documentation:
1. Death Claim Form:
Part 1 – Completed by the Employer/Administrator
Part 2 -Completed by the Beneficiary(ies)
2. Original, photocopy or screen print of enrollment form, including any beneficiary changes.
3. A certified copy of the official death certificate.
4. If the benefits are based on salary, submit payroll records verifying the employee’s annual earnings
at the time of their death.
5. If any portion of coverage is paid for by the employee, submit proof of payroll deduction.
6. For accidental death benefits, provide the below items, including but not limited to:
a. Official completed police report
b. Proof of seatbelt/airbag use if applicable
c. Newspaper clipping(s) of accident, if applicable
d. Coroner’s report, findings and/or toxicology report
7. If the beneficiary is:
a. A Minor – We require copies of guardianship papers naming the legal guardian of the
minor’s estate
b. An Estate – We require the Letters Testamentary or Letters of Administration appointing the
personal representative of the estate
c. Deceased – We require a certification and documentation of the secondary beneficiary.
8. Please have the beneficiary carefully read and complete the Beneficiary Statement which contains
information about the Dearborn National Freedom Account. Unless otherwise requested by the
Beneficiary, benefits amounts of $10,000 or more will be paid using the Dearborn National Freedom
Account. (Not available in AK or KS.)
The Dearborn National Freedom Account is a convenient, interest-bearing checking account into which the
beneficiary’s life insurance proceeds are deposited. The beneficiary earns a competitive rate of interest while taking
the time to contemplate financial decisions that often follow the death of someone close.
A checkbook will be mailed once the claim is approved. All accountholders will receive a monthly statement informing
them of their account balance, activity and interest earnings.
Products and services marketed under the Dearborn National™ brand and the star logo are underwritten and/or provided by Fort Dearborn Life Insurance Company®
(Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands and Guam.
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Death Claim Form
Group Life and Accidental Death Insurance
Return to Dearborn National at:
Attention: Claims Department
P.O. Box 655403
Dallas, Texas 75265-5403
Phone Number: (800) 778-2281
Fax: (972) 996-9361
Part 1 – To be completed by Employer/Administrator
Statement of Employer
Employer/Plan Information
Group Name ___________________________________ Subsidiary Name _______________________________
Group Number _________________________________
Address: _____________________________________________ __________________________ ____________
Street
City
State/Zip
Name and Title of Authorized Representative ________________________________________________________
Phone Number _________________________________ Fax Number _________________________________
E-Mail Address _______________________________________________________________________________
Deceased Person Information
Employee Name ____________________________________________________________________________
Name of Deceased ________________________________ Relation to Employee ________________________
Employee Social Security No. _______________ Date of Birth _____________Date of Death ______________
Address: _____________________________________________ ________________________ ____________
Street
City
State/Zip
Hire Date ________________ Insurance Effective Date _____________ Occupation ______________________
Annual Salary ________________________ Date of Last Salary Increase ____________________________
Amount of Insurance: Basic Life
____________
Additional Benefits:
Seat Belt ___________
Supplemental Life ____________
Air Bag ___________
AD&D
____________
Other ___________
Voluntary Life
____________
___________
Dependent Life
____________
___________
Last Day Worked __________________ Reason for cessation of work: _________________________________
If Disabled, Provide date of disability ___________________________ If deceased is a dependent spouse or child, complete the following:
Dependent’s most recent Employer _________________________________ Last Day Worked _________________
If dependent is a child, is he/she a full-time student? q Yes
q No
Name of School _________________________
I certify that I have read this document and the information is accurate and complete. I understand that any
person who knowingly files a statement of claim containing any false or misleading information may be subject
to criminal and civil penalties.
Signature of Authorized Employer/Plan Representative __________________________________________________
Print Name __________________________________________________ Date_____________________________
Products and services marketed under the Dearborn National™ brand and the star logo are underwritten and/or provided by Fort Dearborn Life Insurance Company®
(Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands and Guam.
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Death Claim Form
Group Life and Accidental Death Insurance
Return to Dearborn National at:
Attention: Claims Department
P.O. Box 655403
Dallas, Texas 75265-5403
Phone Number: (800) 778-2281
Fax: (972) 996-9361
Part 2 – To be completed by Beneficiary
*If there is more than one beneficiary, each must complete a separate form.
Name ________________________________________________________________________________________
Last
First
Middle
Date of Birth _______________________ Social Security No. ______________________
Address _____________________________________________________________________________________
Street
City
State
Zip
Phone ____________________________ E-mail ____________________________________________________
Relationship to deceased ___________________________
Are you a U.S. Citizen: q Yes
q No (If No – IRS Form W-8 required)
Certification
Under penalty of perjury, I certify that:
1. The number shown on this form is my correct Social Security/Taxpayer Identification number; and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or
(b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup
withholding as a result of a failure to report all interest or dividends, or (c) the IRS notified me
that I am not longer subject to backup withholding: and
3. I am a U.S. citizen or other U.S. person.
NOTE: Certification Instructions – You must cross out item 2 above if you have been notified by the IRS that
you are currently subject to backup withholding because of underreporting interest or dividends on your tax
return.
The IRS does not require your consent to any provision of this document other than the certifications required to avoid
backup withholding.
Your Signature ______________________________________________ Date ______________________________
Printed Name _______________________________________________
Products and services marketed under the Dearborn National™ brand and the star logo are underwritten and/or provided by Fort Dearborn Life Insurance Company®
(Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands and Guam.
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Death Claim Form
Group Life and Accidental Death Insurance
Return to Dearborn National at:
Attention: Claims Department
P.O. Box 655403
Dallas, Texas 75265-5403
Phone Number: (800) 778-2281
Fax: (972) 996-9361
Method of Payment
Dearborn National Freedom Account*
If your benefit payment is scheduled to be $10,000 or more, Dearborn National will establish an interest bearing
checking account in your name, unless you have requested otherwise. The Dearborn National Freedom Account
is a safe and secure interest bearing checking account into which life proceeds are deposited. With the Dearborn
National Freedom Account you are able to earn a competitive rate of interest on the life insurance proceeds while
taking your time to weigh the important financial decisions that often follow a life changing event.
The Dearborn National Freedom Account provides you immediate access to your benefit funds. The benefits of the
account include:
Flexibility – During this stressful time you are given the flexibility and time to make important financial decisions and decide the best options for your financial future.
Security – All amounts are fully protected and guaranteed by Fort Dearborn Life Insurance Company.
Free – As long as your account remains open, you will receive monthly statements and have access to
unlimited free checks.
Accessibility – You can write checks for any amount of $250.00 or more to use as you wish.
Interest – Your account will earn interest beginning on the day it is opened. Interest is compounded daily and
credited to your account each month. Your monthly statements will provide additional details on
your balance.
Once your claim is approved, you will receive a checkbook and an implementation kit within 72 hours explaining the
benefits of the Dearborn National Freedom Account. Once established, you will have access to 24 hour customer
service.
Your implementation kit will contain the following:
- Copy of the required Privacy Letter outlining the steps we take to ensure your privacy.
- A detailed booklet containing information and frequently asked questions on the Dearborn National Freedom
Account and how it works.
- A confirmation certificate containing information on your account and the benefit amount that was placed into the
account.
*Not available in Alaska or Kansas
Products and services marketed under the Dearborn National™ brand and the star logo are underwritten and/or provided by Fort Dearborn Life Insurance Company®
(Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands and Guam.
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Death Claim Form
Group Life and Accidental Death Insurance
Return to Dearborn National at:
Attention: Claims Department
P.O. Box 655403
Dallas, Texas 75265-5403
Phone Number: (800) 778-2281
Fax: (972) 996-9361
AUTHORIZATION FOR RELEASE OF INFORMATION
I (the undersigned) authorize any physician, medical professional, pharmacist or other provider of health care
services, hospital, clinic, other medical or medically related facility; coroner’s office; insurance or reinsurance
company; government agency; department of labor; law enforcement or public safety department; group policyholder;
employer; or policy or benefit plan administrator to release information from the records of:
Claimant/Insured Name:________________________________________________________________________
Last
First
Middle
Claimant/Insured Information to be released:
• Data or records regarding medical history, treatment, prescriptions, consultations, autopsy (including
medical and psychological reports; records, charts, notes – excluding psychotherapy notes -, x-rays,
films or correspondence, and any medical condition(s));
• Any information regarding insurance coverage; and
• Accident report or any official investigative reports (such as police, fire, FAA, OSHA, or toxicology report).
• Information to be released to:
Fort Dearborn Life Insurance Company
P.O. Box 655403
Dallas, Texas 75265-5403
• I understand the information obtained by use of this Authorization will be used by Fort Dearborn Life
Insurance Company (The Company) to evaluate my claim for death benefits. The Company will only
release such information:
- To its reinsurer, or other persons or organizations performing business or legal services in
connection with my claim(s); or
- As otherwise may be required by law or as I further authorize.
I further understand that refusal to sign this Authorization may result in the denial of benefits.
• I understand the information used or disclosed may be subject to re-disclosure by the recipient and
may no longer be protected by federal law.
• I understand that I may revoke this Authorization in writing at any time, except to the extent;
- The Company has taken action in reliance on this Authorization; or
- The company is using this Authorization in connection with a contestable claim.
If written revocation is not received, this Authorization will be considered valid for a period of time not
to exceed 24 months from the date of signature below. To initiate revocation of this Authorization, direct all
correspondence to the company at the above address.
• A photocopy of this Authorization is to be considered as valid as the original.
• I understand I am entitled to receive a copy of this Authorization.
SIGNATURE: _____________________________________________________ DATE: _____________________
Print Name: ______________________________________________________
Claimant/Legal representative (Nearest relative, legal guardian, or appointed representative to sign only if claimant/
insured is a minor, legally incompetent, or deceased.) Power of attorney or guardianship must be attached.
Relationship to Claimant/Insured or personal/legal representative signing for Claimant/Insured: ________________
ADDRESS: ________________________________________________PHONE NO. _______________________
Street
________________________________________________
City
State
Zip
Products and services marketed under the Dearborn National™ brand and the star logo are underwritten and/or provided by Fort Dearborn Life Insurance Company®
(Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands and Guam.
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Fraud Notices
Administrative Offices: Downers Grove, Illinois | Dallas, Texas
The laws of some states require us to furnish you with the following notice:
For Applications and Claims:
Colorado: It is unlawful to knowingly provide false,
incomplete, or misleading facts or information to an
insurance company for the purpose of defrauding or
attempting to defraud the company. Penalties may
include imprisonment, fines, denial of insurance, and
civil damages. Any insurance company or agent of
an insurance company who knowingly provides false,
incomplete, or misleading facts or information to a
policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder or claimant with
regard to a settlement or award payable from insurance
proceeds shall be reported to the Colorado division of
insurance within the department of regulatory agencies.
District of Columbia: WARNING: It is a crime to
provide false or misleading information to an insurer
for the purpose of defrauding the insurer or any other
person. Penalties include imprisonment and/or fines. In
addition, an insurer may deny insurance benefits if false
information materially related to a claim was provided by
the applicant.
Florida: Any person who knowingly and with intent to
injure, defraud, or deceive any insurer files a statement
of claim or an application containing any false,
incomplete, or misleading information is guilty of a felony
of the third degree.
Hawaii: For your protection, Hawaii law requires you be
informed that presenting a fraudulent claim for payment
of a loss or benefit is a crime punishable by fines or
imprisonment, or both.
Kentucky: Any person who knowingly and with intent
to defraud any insurance company or other person files
an application for insurance or a statement of claim
containing any materially false information or conceals,
for the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act,
which is a crime.
New Mexico: Any person who knowingly presents a
false or fraudulent claim for payment of a loss or benefit
or knowingly presents false information in an application
for insurance is guilty of a crime and may be subject to
civil fines and criminal penalties.
Ohio: Any person who, with intent to defraud or
knowingly that he is facilitating a fraud against an insurer,
submits an application or files a claim containing a false
or deceptive statement is guilty of insurance fraud.
Oklahoma: Any person who knowingly, with intent to
injure, defraud or deceive any insurer, makes a claim
for the proceeds of an insurance policy containing false,
incomplete or misleading information is guilty of a felony.
Pennsylvania: Any person who knowingly and with
intent to defraud any insurance company or other person
files an application for insurance or statement of claim
containing any materially false information or conceals for
the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act,
which is a crime and subjects such person to criminal
and civil penalties.
Puerto Rico: Any person who knowingly and with the
intention of defrauding presents false information in an
insurance application, or presents, helps, or causes the
presentation of a fraudulent claim for the payment of
a loss or any other benefit, or presents more than one
claim for the same damage or loss, shall incur a felony
and, upon conviction, shall be sanctioned for each
violation with the penalty of a fine of not less than five
thousand dollars($5,000) and not more than ten thousand
dollars ($10,000), or a fixed term of imprisonment for
three (3) years, or both penalties. Should aggravating
circumstances are present, the penalty thus established
may be increased to a maximum of five (5) years,
if extenuating circumstances are present, it may be
reduced to a minimum of two (2) years.
Louisiana: Any person who knowingly presents a false
or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for
insurance is guilty of a crime and may be subject to fines
and confinement in prison.
Rhode Island: Any person who knowingly presents a
false or fraudulent claim for payment of a loss or benefit
or knowingly presents false information in an application
for insurance is guilty of a crime and may be subject to
fines and confinement in prison.
Maryland: Any person who knowingly and willingly
presents a false or fraudulent claim for payment of a loss
or benefit or who knowingly and willfully presents false
information in an application for insurance is guilty of a
crime and may be subject to fines and confinement in prison.
Virginia: It is a crime to knowingly provide false,
incomplete or misleading information to an insurance
company for the purpose of defrauding the company.
Penalties include imprisonment, fines and denial of
insurance benefits.
Maine & Washington: It is a crime to knowingly
provide false, incomplete, or misleading information to
an insurance company for the purpose of defrauding the
company. Penalties include imprisonment, fines and
denial of insurance benefits.
Tennessee: It is a crime to knowingly provide false
incomplete or misleading information to an insurance
company for the purpose of defrauding the company.
Penalties include imprisonment, fines and denial of
insurance benefits
Products and services marketed under the Dearborn National™ brand and the star logo are underwritten and/or provided by Fort Dearborn Life Insurance Company®
(Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands and Guam.
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Fraud Notices
Administrative Offices: Downers Grove, Illinois | Dallas, Texas
The laws of some states require us to furnish you with the following notice:
FOR CLAIMS ONLY:
FOR APPLICATIONS ONLY:
Alaska: A person who knowingly and with intent to
injure, defraud, or deceive an insurance company files
a claim containing false, incomplete, or misleading
information may be prosecuted under state law.
Arizona: For your protection, Arizona law
requires the following statement to appear on
this form. Any person who knowingly presents
a false or fraudulent claim for payment of a loss
is subject to criminal and civil penalties.
Massachusetts: Any person who knowingly presents a
false or fraudulent claim for payment of a loss or benefit
or knowingly presents false information in an application
for insurance is guilty of a crime and may be subject to
fines and confinement in prison.
New Jersey: Any person who includes any false or
misleading information on an application for an insurance
policy is subject to criminal and civil penalties.
Arkansas: Any person who knowingly presents a false
or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for
insurance is guilty of a crime and may be subject to fines
and confinement in prison.
California: For your protection California law requires
the following to appear on this form. Any person who
knowingly presents false or fraudulent claim for the
payment of a loss is guilty of a crime and may be subject
to fines and confinement in state prison.
Delaware: Any person who knowingly, and with intent to
injure, defraud or deceive any insurer, files a statement
of claim containing any false, incomplete or misleading
information is guilty of a felony.
Idaho: Any person who knowingly, and with intent
to defraud or deceive any insurance company, files
a statement or claim containing false, incomplete, or
misleading information is guilty of a felony.
Indiana: A person who knowingly and with intent to
defraud an insurer files a statement of claim containing
any false, incomplete, or misleading information commits
a felony.
Minnesota: A person who files a claim with intent to
defraud or helps commit a fraud against an insurer is
guilty of a crime.
New Hampshire: Any person who, with a purpose to
injure, defraud or deceive any insurance company, files
a statement of claim containing any false, incomplete
or misleading information is subject to prosecution and
punishment for insurance fraud, as provided in RSA
638:20.
New Jersey: Any person who knowingly files a
statement of claim containing any false or misleading
information is subject to criminal and civil penalties.
Texas: Any person who knowingly presents a false or
fraudulent claim for the payment of a loss is guilty of a
crime and may be subject to fines and confinement in
state prison.
Products and services marketed under the Dearborn National™ brand and the star logo are underwritten and/or provided by Fort Dearborn Life Insurance Company®
(Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands and Guam.
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