Fillable Aflacny Initial Waiver Of Premium Claim Form V8 16

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Aflacny Initial Waiver Of Premium Claim Form V8 16

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The Aflacny Initial Waiver Of Premium Claim Form V8 16 form is 8 pages long and contains:

  • 5 signatures
  • 58 check-boxes
  • 126 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
Initial Waiver of Premium Claim NY
INSTRUCTIONS
• Complete Section A- Insured Information section of this claim form. The Insured
must sign and date the Disclosure Authorization section of this claim form. The
Insured should also complete the Education & Training Evaluation form provided
separately.
• Section B – Employer Statement must be completed by your employer confirming
your last day worked.
• Have the physician complete Section C – Attending Physician’s Statement within
this form and the Functional Capacity Evaluation form provided separately.
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
Initial Waiver of Premium Claim NY
Section A – Insured Information Policy / Certificate #: _________________
Name: ______________________________________ DOB: ____/____/____ SSN: _______________________
Address: _____________________________________________________________________________________________
Street City State Zip Code
Phone #________________________ Home Cell Work E-Mail Address: ___________________________________________
Employer Name & Address : ____________________________________________________________________________________
Name Address City State Zip Code
Date Employed: ___/___/___ Occupation _________________________________________________________________________
Principal Duties:______________________________________________________________________________________________
Doctors Consulted:
___________________________________________________________________________________________________________
Name Address Dates
___________________________________________________________________________________________________________
Name Address Dates
___________________________________________________________________________________________________________
Name Address Dates
Name of Hospital: _____________________________________ Date Admitted: ___/___/___ Date Discharged: ___/___/___
Describe nature of illness or injury: _______________________________________________________________________________
If Illness, what date did you first notice the illness? ___/___/___
If Accident, on what date? ___/___/___ Where you at work?
Yes No
How did it happen? ____________________________________________________________________________________
Date & time you stopped working: ___/___/___ ____________
AM PM
Dates you were continuously confined to your home: From: ___/___/___ To: ___/___/___
Date & time you resumed working: ___/___/___ ____________
AM PM
If unable to resume work at present, about what date should you be well enough to resume work? ___/___/___
Are you making claim with any other company? Yes No
If yes, please provide:
___________________________________________________________________________________________________________
Company Name Amount of Policy
___________________________________________________________________________________________________________
Company Name Amount of Policy
*** 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
Initial Waiver of Premium Claim NY
Section B – Employer Statement
This statement must be completed by the supervisor or timekeeper of the employer. If the insured is self-
employed, the insured will complete the following statement giving all the details.
Name of Employee: _________________________________________________________ Policy #: ________________________
Occupation of the insured at the time of disability: ___________________________________________________________________
Employed how many days per week? _________________
Average monthly earnings? $_______________
Date & time employee last worked: ___/___/___ ____________ AM PM
Date & time employee returned to work: ___/___/___ ____________
AM PM
Occupation of which the insured returned?: _______________________________________________________________________
Company Name: ____________________________________________________________________________________________
Address: _____________________________________________________________________________________________
Street City State Zip Code
Printed name _____________________________________________ Official Title _____________________________
Phone: _____-_____-_______ Fax: _____-______-_____
Signature___________________________________________ Date ____/____/____
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signature
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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
Initial Waiver of Premium Claim NY
Section C – Attending Physician’s Statement (To be completed by the Attending Physician)
Name of Patient: ____________________________________ Patient I.D. Number: ________________________
1. History
When did present illness begin or injury occur? ___/___/___ Date patient was obligated to cease work? ___/___/___
Is there a previous history of this illness? Yes No
If yes, when and describe: ______________________________________________________________________________
2. Present Condition
Subjective symptoms: ________________________________________________________________________________________
Objective findings:____________________________________________________________________________________________
Give report of X-rays, EKG’s, or any other special tests
Is patient: Ambulatory House Confined Bed Confined Hospital Confined
3. Diagnosis (including any complications)
Diagnosis: _________________________________________________________________________________________________
__________________________________________________________________________________________________________
4. Dates of Treatment
Date of 1
st
visit: ___/___/___ Date of last visit: ___/___/___ Frequency: Weekly Monthly Other _________________
5. Nature of Treatment (including Surgery & medications prescribed, if any)
Treatment: _________________________________________________________________________________________________
Will treatment substantially improve function and employability?
Yes No
Names & addresses of other treating physicians:
___________________________________________________________________________________________________________
Name Address
___________________________________________________________________________________________________________
Name Address
6. Progress
Has patient: Recovered Improved Unchanged Retrogressed
Is patient:
Ambulatory House Confined Bed Confined
7. Physical Impairment (Please check one)
Class 1 - No limitation of functional capacity; capable of heavy physical activity. No restrictions. (0-10%)
Class 2 - Slight limitation of functional capacity; capable of light manual activity. (15-30%)
Class 3 - Moderate limitation of functional capacity; capable of clerical/administrative (sedentary) activity. (35-55%)
Class 4 - Marked limitation. (60-70%)
Class 5 - Severe limitation of functional capacity.
Remarks: __________________________________________________________________________________________________
8. Mental / Nervous Impairment (if applicable)
Class 1 - Patient is able to function under stress & engage in interpersonal relations (no limitations).
Class 2 - Patient is able to function in most stress situations & engage in most interpersonal relations (slight limitations).
Class 3 - Patient is able to engage in only limited stress situations & engage in only limited interpersonal relations (moderate
limitations).
Class 4 - Patient is unable to engage in stress situations or engage in interpersonal relations (marked limitations).
Class 5 - Patient has significant loss of psychological, physiological, personal and social adjustment (severe limitations).
Remarks: __________________________________________________________________________________________________
Do you believe the patient is competent to endorse checks and direct the use of the proceeds thereof?
Yes No
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
Initial Waiver of Premium Claim NY
Section C – Attending Physician’s Statement (Continued)
9. Prognosis
Patient’s Job
Any Other Work
Is the patient now totally disabled?
Yes
No
Yes
No
Do you expect a fundamental or
marked change in the future?
Yes No Yes No
If yes, when will patient recover
sufficiently to perform duties?
___/___/___
1 Mo
1-3 Mos
3-6 Mos
Never
___/___/___
1 Mo
1-3 Mos
3-6 Mos
Never
If no, please explain:
Date released to work:
___/___/___
___/___/___
10. Rehabilitation
Patient’s Job
Any Other Work
Is the patient a suitable candidate
for trial employment?
Yes No Yes No
If yes, when could trial employment
commence?
___/___/___
Full-Time
Part-Time
___/___/___
Full-Time
Part-Time
If yes, what training will patient require?
If no, please explain:
11. Remarks
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Physician’s name (please print)_____________________________________________ Specialty_____________________________
Phone: _____-_____-_______ Fax: _____-______-_____
Address: _____________________________________________________________________________________________
Street City State Zip Code
Authorization: I hereby authorize the hospital to release information to this patient to the TRUSTMARK LIFE INSURANCE COMPANY
OF NEW YORK or its representative.
Physician Signature___________________________________________ Date ____/____/____
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signature
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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
Initial Waiver of Premium 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.
Date___/___/___ Signature: _________________________________________________________
Date of Birth ___/___/___ Relationship, if other than insured: _______________________________________
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signature
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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
Initial Waiver of Premium Claim NY
Insured Statement of Claim – Communication
1. 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 Signature Date
Printed Name Social Security Number
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signature
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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
Initial Waiver of Premium Claim NY
Insured Statement of Claim – Communication (Continued)
2. Third Party Communication Authorization
Please complete this authorization if you would like us to discuss, to release, or to provide information to a family
member, friend, or other third party such as your agent or employer.
My Spouse or Partner: (Name)_______________________________________________________________________
☐ All Information (All policy and claim information)
☐ All Information except Medical Information (diagnosis, medical condition, reason for claim, treatment, physicians)
My Family Member: (Name and Relationship)_____________________________________________________________
☐ All Information (All policy and claim information)
☐ All Information except Medical Information (diagnosis, medical condition, reason for claim, treatment, physicians)
Other Third Party: My Agent: Yes ☐ My Employer: Yes ☐
Or Name a Specific Third Party (Name and Relationship) ___________________________________________________
☐ All Information (All policy and claim information)
☐ All Information except Medical Information (diagnosis, medical condition, reason for claim, treatment, physicians)
I agree that if I authorize release of all claim information this may include health information which may be related to
disorders of the immune system including but not limited to HIV and AIDS, use of alcohol or drugs, mental and physical
condition, history, or treatment.
I understand that any information shared may be subject to re-disclosure and might not be protected by certain federal
regulations governing the privacy of health information relative to my condition.
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 Policy Owner’s Personal Representative’s Signature Date
- -
Printed Name Social Security Number
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Aflacny Initial Waiver Of Premium Claim Form V8 16

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Completed 2 July 2020

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