Fillable Accelerated Life Proof of Loss Claim Statement

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Accelerated Life Proof of Loss Claim Statement

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EF-1205
IMPORTANT INFORMATION REGARDING APPLICATION FOR BENEFITS
This form is to be attached to the proof of Loss Claim Statement when a claim is submitted to
Reliance Standard Life. Please be sure that all responsible parties completing and filing a claim
for benefits are aware of the following statements which concern claim fraud and abuse:
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.
State of California
For your protection, California law requires the following to appear on this form: 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.
State of Florida
Any person who knowingly and with intent to injure, defraud, or deceive any insurer, files a
statement of claim or an application containing false, incomplete or misleading information is
guilty of a felony of the third degree.
State of New Jersey
Any person who knowingly files a statement of claim containing any false or misleading
information is subject to criminal and civil penalties.
State of New York
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 shall also be subject to a civil
penalty not to exceed five thousand dollars and the stated value of the claim for each such
violation.
State of Ohio
Any person who, with intent to defraud or knowing 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.
State of Oregon
Any person who, with an intent to knowingly 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, may be subject to prosecution for insurance fraud.
State of 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.
EF-1017
EMPLOYER/ADMINISTRATOR INSTRUCTIONS
The Employer/Administrator must complete PART A in its entirety. The Claimant should complete, sign and date PART B, the Authorization for Use in
Obtaining Information form and PART C in their entirety. Part D must be completed by the attending physician without expense to RSL.
Return this form to: Reliance Standard Life Insurance Company
Attn: Group Life Claims
P.O. Box 7307
Philadelphia, PA 19101-7307
Phone 1-800-351-7500
In addition to the claim form, the following items are required:
1. Copies of enrollment forms and any subsequent changes;
2. Proof of earnings (as defined by the applicable policy) and, if the employee is required to pay all or part of the premiums for this insurance, copies of
payroll records for a two (2) month period prior to date last worked to confirm premium payments.
Additional medical information may be required from the physician and an independent medical examination may be requested by RSL. A notarized
consent must be received from any Irrevocable Beneficiary and any Assignee. RSL must comply with all state regulations. This may delay processing
of the claim.
PART A: EMPLOYER/ADMINISTRATOR INFORMATION
Employer Name and Address
List all Applicable RSL Policy Numbers Under
Which a Claim is Being Made
Division Name and Address N/A
Employee Social Security Number
Employee Name and Address
Bill Group Number (if applicable)
Is Employee’s Insurance
Currently In Force? Yes  No
Date Coverage Terminated
Date of Birth
Employee Occupation/Title/Position
Effective Date of Coverage for
Employee
Insurance Class (Refer to Policy
Schedule of Benefits)
Class 1 if act. retirees
Salary on Last Benefit Change Date
$ Hrly Wkly
Mthly Annly
Date Premium Paid To On
Employee's Behalf
Life Insurance In Force
$
Accelerated Benefit Amount Requested
(based on the limits stated in the policy)
$
Date of Last Benefit Increase (Refer to Policy Schedule of
Benefits)
Current Status of Employee
Active Retired Premium Waiver for Disability Approved Leave of Absence (Explain) Other (specify) _______________________
Number of Hours Employee
Scheduled to Work Per Week
Is Employee Still Working?
Yes No
Date Employee Last Worked
Reason Employee Did Not Return to Work
Employee Is (Was):
Full-time Union Hourly Exempt  Commissioned
(Check All That Apply) Part-time Non-Union Salaried Non-Exempt Other (Explain)
AUTHORIZED EMPLOYER/ADMINISTRATOR SIGNATURE
Any person who knowingly and with intent to injure, defraud or deceive Reliance Standard Life Insurance Company, files a statement of claim or submits
any information in conjunction with a claim containing fraudulent, false, misleading, incomplete or deceptive information commits a fraudulent insurance
act, which is a crime. These actions will result in the denial of the claim, and are subject to prosecution under state and/or federal law. Reliance Standard
Life Insurance Company will cooperate fully with any prosecution and will seek any and all appropriate legal remedies.
Phone Number ( )
Fax Number ( )
E-mail Address
Name (Please Print)
Employer/Administrator Signature Date
PART B: IMPORTANT TAX INFORMATION To be completed by Employee
To Be Completed By Claimant
Under penalties of perjury, I certify (1) that the Social Security Number shown on this form
is my correct Social Security Number or Taxpayer Identification Number and (2) that I am
not subject to backup withholding as a result of a failure to report all interest or dividends;
or the Internal Revenue Service has notified me that I am no longer subject to backup
withholding. (Strike out clause (2) if you are currently under notification that you are
subject to backup withholding.)
By signing this form the claimant has read and agrees with the terms of the statement as
well as any accompanying information.
Social Security Number/Tax ID Number
___ ___ ___ ___ ___ ___ ___ ___ ___
Signature of the Claimant:
______________________________________________
Date Signed (month, day, year): _____________________
Be Certain Authorization for Use in Obtaining Information form and Part C are Completed.
Proof of Loss Claim Statement
Group Life Accelerated Benefit
Reset
P.O. Box 8330
Philadelphia, PA 19101-8330
(800) 351-7500 Fax: (267) 256-4262
EF-1217
AUTHORIZATION FOR USE IN OBTAINING INFORMATION
NAME OF INSURED: _________________________________________________
INSURED'S DATE OF BIRTH: _________________________________________
POLICYHOLDER: ___________________________________________________
To all physicians and other health care professionals, hospitals, other health care institutions,
insurers, medical, hospital and prepaid health plans, pharmacies, pharmacy benefit managers,
employers, group policyholders, contract holders, governmental agencies (including but not limited to
the Internal Revenue Service and the Social Security Administration), private and/or public benefit
plan administrators, and/or attorney representatives, including but not limited to covered entities and
business associates under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”)
and the accompanying regulations:
You are authorized to provide Reliance Standard Life Insurance Company and/or its authorized
administrators, including but not limited to Matrix Absence Management, with information concerning
medical care, advice, and/or treatment provided to me, the above named Insured, and/or any
employment, salary, tax and/or benefit-related information concerning me, the above named Insured.
I understand that the disclosure of information may include disclosure of protected health information
under HIPAA and the accompanying regulations, information regarding treatment for mental illness,
the human immunodeficiency virus (HIV) and/or the use of drugs and alcohol. I also understand that
information used or disclosed pursuant to this authorization may be subject to redisclosure by the
recipient and will no longer be subject to protection under HIPAA and the accompanying regulations.
A statement of Reliance Standard Life Insurance Company’s privacy policy is available at
www.rsli.com or upon request.
Reliance Standard Life Insurance Company will not condition the provision of treatment, payment,
enrollment in a health plan, or eligibility for benefits on the provision of this Authorization, except that
this Authorization may be required to allow a covered entity to disclose protected health information
where such disclosure is necessary to evaluate my claim for benefits.
I understand that any such information will be used for the purpose of evaluating my claim for
benefits. Upon request, I understand that I am entitled to receive a copy of this Authorization. This
Authorization is valid from the date signed for the duration of the claim, and may be revoked by me at
any time upon written request to the address above. A reproduction of this Authorization shall be
considered as valid as the original.
_________________________ ___________________________________
Date Insured's Signature
(If the Insured is unable to sign, an authorized person may sign.)
__________________________ ___________________________________
Date Authorized Person's Signature
Description of Authorized Person’s authority to sign on behalf of Insured:
___________________________________________________________________
EF-1017
PART C: CLAIMANT INFORMATION
In order to assure prompt processing, please be certain the Authorization for Use in Obtaining Information is signed and dated. The completed and signed claim
form including PART D below should be returned to the Employer/Administrator. The payment of the Accelerated Benefit will reduce the Death Benefit
under your Life Insurance.
Important tax information: Accelerated Benefits may be considered taxable income and assistance should be sought from a personal tax advisor. Receipt of
these benefits may affect your eligibility for other government programs such as Medicaid and Supplemental Security Income (SSI).
Name of Claimant
Relationship
To Employee
Date of Birth
E-mail Address
"I herby request Reliance Standard Life to accelerate the portion of my term life insurance coverage specified on this claim statement. This request is being
made voluntarily and without coercion on the part of any third party. I understand that receipt of an accelerated benefit may affect my eligibility for a state or
federal program such as Medicaid, and that these benefits may be taxable. I also understand that the death benefit will be reduced if I receive an accelerated
benefit."
Any person who knowingly and with intent to injure, defraud or deceive Reliance Standard Life Insurance Company, files a statement of claim or
submits any information in conjunction with a claim containing fraudulent, false, misleading, incomplete or deceptive information commits a
fraudulent insurance act, which is a crime. These actions will result in the denial of the claim, and are subject to prosecution under state and/or
federal law. Reliance Standard Life Insurance Company will cooperate fully with any prosecution and will seek any and all appropriate legal remedies.
Signature of Claimant Date
Home Phone Number
( )
Business Phone Number
( )
Address of Claimant (No., Street, City, State, Zip)
PART D: ATTENDING PHYSICIAN'S STATEMENT
Instructions to Physician: Please complete each section of this form and provide all reports and treatment records pertaining to this patient. The
Claimant is responsible for the completion of this statement without expense to the Company.
Patient's Name
Date of Birth
Principle Diagnosis INCLUDING ICD-9 or ICD-10 CODE
Date of Onset
Contributing Cause INCLUDING ICD-9 or ICD-10 CODE
Date of Onset
Objective findings (attach results of x-rays, lab tests, EKGs, MRIs, and scans). Provide most recent lab values and diagnostic test results.
Describe Treatment programs, including surgery or medications (attach copies of treatment records)
I attended patient: From (date of first visit) To (date of treatment) Frequency of visits (treatment)
Is patient now totally and continuously disabled? Yes No
If "Yes," please state date on which total and continuous disability began:
Please provide the name(s) and address(es) of any other physician currently treating this patient:
In your opinion, does the patient possess the mental capacity to understand his/her financial affairs and to direct the use of his/her funds?
Yes No
Based upon this patient's medical condition and your current clinical findings, does this patient have a Life Expectancy of:
Less than 12 months More than 12 months, but less than 24 months Greater than 24 months Cannot be determined
What is this patient's prognosis?
Any person who knowingly and with intent to injure, defraud or deceive Reliance Standard Life Insurance Company, files a statement of claim or
submits any information in conjunction with a claim containing fraudulent, false, misleading, incomplete or deceptive information commits a
fraudulent insurance act, which is a crime. These actions will result in the denial of the claim, and are subject to prosecution under state and/or
federal law. Reliance Standard Life Insurance Company will cooperate fully with any prosecution and will seek any and all appropriate legal remedies.
Physician’s Specialty
Tax Identification Number
Physician's Name (please print or type)
Address (No., Street, City, State, Zip Code)
Physician’s Signature Date
Phone Number
( )
Fax Number
( )
REMINDER: PLEASE PROVIDE ALL REPORTS AND TREATMENT RECORDS PERTAINING TO THIS PATIENT.
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Accelerated Life Proof of Loss Claim Statement

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Completed 20 November 2019

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