Fillable Aflacny Death Benefit Claim Form V8 16

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Aflacny Death Benefit Claim Form V8 16

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The Aflacny Death Benefit Claim Form V8 16 form is 4 pages long and contains:

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  • 6 check-boxes
  • 106 other fields

Country of origin: US
File type: PDF

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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, Albany, NY AflacNY V8.16
Administrative Office: PO Box 60676, Worcester, MA 01606
Death Benefit Claim NY
Instructions
• The Statement of Physician section must be completed by the deceased’s primary care physician, ONLY if the death
occurred within the first two (2) years from the effective date of the policy.
• A Beneficiary’s Statement must be completed by the person to who the insurance is payable. In connection with such
statement, the following should be observed:
1. If there is more than one beneficiary, all may join in one statement or a separate form will be furnished for each if
desired.
2. If the policy is payable to the estate or to the executors or administrators of the insured, the statement should be
completed by
the executor or administrator, a certificate of whose appointment and qualifications must be furnished.
3. If the policy is payable to a minor or a mentally incompetent person, the statement should be completed by a
guardian, a
certificate of whose appointment and qualifications must be furnished.
4. If the policy has been assigned, special instructions will be furnished.
• A Certified Copy of the Death Certificate must be furnished for insured.
• A Certified Copy of the Death Certificate for any deceased beneficiary must be furnished.
• If the cause of death is due to an injury or accident, please enclose a photocopy of the police report and/or newspaper articles
concerning the
circumstances.
Section A – Beneficiary’s Statement
Policy / Certificate #: __________________________
Deceased’s Full Name: _______________________________________________________________
Residence Address: ___________________________________________________________________________________________
Street City State Zip Code
Deceased’s DOB: ____/____/____ Place of birth: _____________________________________________________________
Occupation at death: ____________________________________________________ Date last worked? ____/____/____
Date of death? ____/____/____ Place of death: ______________________________________________________________
Cause of death: ______________________________________________________________________________________________
When did deceased first complain of or give other indications of the last illness? ____/____/____
When did deceased first consult a physician for the last illness? ____/____/____
Names & addresses of all physicians or practitioners who attended or prescribed for deceased within the five years preceding death
Physician Name Address Dates of Attendance Disease or Condition
Has deceased at any time been confined to a hospital? Yes No If yes, when? ____/____/____
If yes, where? _______________________________________________________________________________________________
If optional settlement is available, and you do not desire payment in one sum, state type of settlement desired: __________________
__________________________________________________________________________________________________________
*** Complete & Sign Disclosure Authorization Portion of Claim Form ***
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, Albany, NY AflacNY V8.16
Administrative Office: PO Box 60676, Worcester, MA 01606
Death Benefit Claim NY
Section B – Attending Physician’s Statement (To be completed by the Attending Physician)
Deceased’s Full Name: _________________________________________________ Age At Death: ________________________
Residence at death: ________________________________________ Occupation: ______________________________________
How long have you known the deceased? ____________________
Date & Time of death? ____/____/_____ ___________ Place of death: _________________________________________________
If death occurred in hospital, please give name & address: ___________________________________________________________
When you were first consulted for the condition which directly or indirectly caused death: ____/____/____
What was the immediate cause of death? ________________________________________________________________________
How long, in your opinion, did this disease or impairment exist? _______________________________________________________
What was the date of onset of the first symptom or sign according to the clinical history? ____/____/____
From what date was the patient continuously totally disabled prior to death? ___/___/___
Contributory cause of death: ________________________________________________ Duration: ________________________
Other chronic diseases or impairments:________________________________________ Duration: ________________________
If death was due to suicide, homicide, or accident, complete this section
Cause of death: Suicide Homicide Accident
Please describe briefly: ________________________________________________________________________________________
Was an official inquiry held? Yes No Was a post-mortem examination made? Yes No
Was blood alcohol level and/or drug level taken? Yes No If yes, findings? ________________________________________
Please give particulars of each condition for which you treated or advised deceased prior to last illness
Disease or Condition Date Duration Result
Please give name & addresses of all other physicians or other practitioners who attended deceased within the five years preceding
death
Physician Name Address Phone Disease or Condition
Physician’s name (please print)_____________________________________________ Specialty_____________________________
Phone: _____-_____-_______ Fax: _____-______-_____
Address: _____________________________________________________________________________________________
Street City State Zip Code
Signature___________________________________________ Date ____/____/____
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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, Albany, NY AflacNY V8.16
Administrative Office: PO Box 60676, Worcester, MA 01606
Death Benefit Claim NY
DISCLOSURE AUTHORIZATION Insured’s Name (Please Print):_____________________________________
I AUTHORIZE any doctor, hospital, clinic, other medical facility or provider of health care, insurer or reinsurer, consumer
reporting agency, insurance support organization, insurance agent, employer, financial institution, the Social Security
Administration, the Internal Revenue Service, the Veterans Administration or any other organization or person having any
knowledge of me or my health to give to Trustmark Life Insurance Company of New York and affiliates or its employee
and agents, or any other consumer reporting agency any information as to cause, treatment, diagnoses, prognoses,
consultations, examinations, tests or prescriptions with respect to my physical or mental condition or information
concerning me, my occupation, employment history, earnings or finances or information otherwise needed to determine
policy claim benefits due me. This may include, but is not limited to, HIV Infection, any disorder of the immune system
including Acquired Immune Deficiency Syndrome (AIDS), driving records, mental illness, or use of alcohol or drugs.
I further AUTHORIZE the Social Security Adm. to release information or records about me to Trustmark Life Insurance
Company of New York or authorized representatives. This information is to be released in order to properly adjudicate my
claim or continue my eligibility for benefits. Please release detailed earnings for up to the last ten years and/or summary
record of total earnings and/or information from master benefit records regarding award, denial or continuing benefits.
This authorization may be revoked by me. Any such revocation must be in writing, must be signed and dated by me and
must be forwarded directly to the Trustmark Life Insurance Company of New York. I AGREE the information obtained with
this Authorization may be used by Trustmark Life Insurance Company of New York and affiliates to determine policy claim
benefits with respect to the Insured. A photocopy of this authorization is as valid as the original and I may request a copy.
This authorization will be in force for the term of coverage of the policy up to 12 months from the date shown below. I
understand that if I revoke or fail to sign this authorization or alter its content it may affect the handling of my claim
including denial of benefits under my policy.
I understand that there is a possibility of redisclosure of any information disclosed pursuant to this authorization and that
information, once disclosed, may no longer be protected by federal rules governing privacy and confidentiality.
I AUTHORIZE Trustmark Life Insurance Company of New York and affiliates to report to ICS, any dates of past or present
claims filed by me.
Residents of NY – 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 or each such violation.
Signature: _______________________________________________ Date Signed: ___/___/___
Printed Name: ___________________________________________ Date of Birth: ___/___/___ SSN: _____________________
Relationship: ____________________________________________ Daytime Phone Number (____) _______-_____________
Residence Address: ___________________________________________________________________________________________
Street City State Zip Code
Signature: _______________________________________________ Date Signed: ___/___/___
Printed Name: ___________________________________________ Date of Birth: ___/___/___ SSN: _____________________
Relationship: ____________________________________________ Daytime Phone Number (____) _______-_____________
Residence Address: ___________________________________________________________________________________________
Street City State Zip Code
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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, Albany, NY AflacNY V8.16
Administrative Office: PO Box 60676, Worcester, MA 01606
Death Benefit Claim NY
Beneficiary Statement of Claim – Communication
CONSENT FOR USE OF ELECTRONIC COMMUNICATIONS (EMAIL, SMS/MMS TEXT MESSAGING)
To ensure the best and fastest communication, we would like to communicate with you using either email or text
messaging. Please complete this section if we can communicate with you electronically, concerning your claim, benefits,
policy, premium or condition.
May we communicate with you electronically?
No
Yes, by Text Messages - Please provide cell phone #: (_____) - ______ - ______
Yes, by Email Please provide email address: ________________________________________@ _______________
If you chose to communicate with us electronically, you should be aware that electronic communication is not secure
unless it is encrypted. We strongly encourage you to use encrypted communication when sending sensitive and/or
confidential information. By sending sensitive or confidential electronic messages that are not encrypted, you accept the
risks of such lack of security and possible lack of confidentiality. If you elect to communicate from your workplace
computer, you should also be aware that your employer and its agents, have access to electronic communication
between you and us.
I understand that by selecting text messaging, regular text messaging rates may apply for any texts I receive from
Trustmark Life Insurance Company of New York and I assume responsibility for any costs associated with these text
messages. This consent shall remain in effect unless revoked in writing.
To ensure a smooth email experience, please be sure that your computer has the most up to date version of Adobe
Reader. You should add our email address to your address book contact list and add us to your email server or spam
filter approved listing. If you don’t see email from us in your email inbox, be sure to check your spam, clutter, junk or
bulk email folder. You can choose to stop electronic communication at any time by revoking this authorization. If you no
longer wish to communicate via electronic means we will correspond with you via US mail. If you require copies of any
communication sent to you by email/text in paper form, please contact us. There is no cost to you to obtain copies of
electronic communication in paper format.
Authorization
I may revoke or update this authorization in writing at any time or by email to
Claims@ULAflac.com.
Trustmark Life Insurance Company of New York may rely on the information I provide for the adjudication of my claim as
a result of this authorization until receipt of my revocation notice. This authorization is valid for two (2) years. I may
request a copy of this authorization and a copy is as valid as the original.
Policy Owner or Beneficiary Signature Date
Printed Name Social Security Number
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Aflacny Death Benefit Claim Form V8 16

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Completed 2 July 2020

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