For Claims Customer Service: Phone: (800) 225-3859
For Claims Submission: Fax: (508) 853-0310 Email: Claims@ULAflac.com
Mail: Attn: Life Claims PO Box 60676, Worcester, MA 01606
Trustmark Life Insurance Company of New York AflacNY V8.16
126 South Swan Street, Suite 203, Albany, NY 12210
Accelerated Death Benefit Claim - NY
Signatures Required
I have read the statement on this form and concur with them. I am of sound mind and have advised my beneficiaries, the executor
of my estate, and my attorney of my action and have instructed that I alone am responsible for seeking this benefit.
New York regulation requires Trustmark Life Insurance Company of New York to provide you with the following notices and
statements: Receipt of accelerated death benefits may affect eligibility for public assistance programs such as medical
assistance (Medicaid), aid to Families with Dependent Children and Supplemental Security Income. Receipt of accelerated
death benefits in periodic payments may be treated differently than receipt in a lump sum. Prior to applying for accelerated
death benefits, you should consult with the appropriate social services agency concerning how receipt will affect the eligibility
of the recipient and/or the recipient’s spouse and dependents.
Receipt of accelerated death benefits may be taxable. Receipt of accelerated death benefits in periodic payments may be
treated differently than receipt in a lump sum. Prior to applying for such benefits, you should seek assistance from a qualified
tax advisor.
By signing this claim form you declare that your application for this benefit is voluntary and without coercion on the part of any
third party.
No health care facility as defined in section 20 of the Public Health Law can require any person to accelerate payment of a death
benefit as a condition of admission to such health care facility or for providing any care in such facility.
Within 5 days of receiving your request that you may want to claim the accelerated death benefit, Trustmark Life Insurance
Company of New York is required to provide you with: 1) a numerical computation of the amount of the death benefit You
requested for acceleration, and the amount to be paid in cash; 2) the amount of your death benefit if you chose not to accelerate
it; 3) an illustration demonstrating the effect of the accelerated death benefit requested on the policy’s face amount, death
benefit, premium payments, accumulation account, cash value, loan balance, and partial withdrawals as provided under the
terms of the policy. Trustmark Life Insurance Company of New York is prohibited from paying accelerated death benefits to you
for 14 days from the date on which this information is transmitted to you in writing. Trustmark Life Insurance Company of New
York reserves the right to charge an administrative fee of up to $250.
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.
New York Regulation requires that this claim form must be completed and signed by Policyowner within 30 days from the
date Trustmark Life Insurance Company of New York transmitted this claim form.
Date of Transmittal: ______________________________________________________________________________________
Return completed claim form to: Trustmark Life Insurance Company of New York, PO Box 60676, Worcester, MA 01606
Insured/Claimant Signature: _________________________________________________________ Date Signed: ___/___/___
Spouse Signature: _________________________________________________________________ Date Signed: ___/___/___
(If a Community Property state. I hereby forever waive all community property right and claims to any funds paid pursuant to the Accelerated Death
Benefit and agree that said check should be made payable to the owner).
Owner Signature: __________________________________________________________________ Date Signed: ___/___/___
(If other than insured)
Joint Owner Signature: _____________________________________________________________ Date Signed: ___/___/___
(If applicable)
Irrevocable Beneficiary Signature: ____________________________________________________ Date Signed: ___/___/___
(If applicable, I hereby forever waive all rights and claims to any funds paid pursuant to the Accelerated Death Benefit and agree that said check should
be made payable to the owner.))
Notarized Signature: _______________________________________________________________ Date Signed: ___/___/___
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