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
Permanent Waiver of Premium Claim NY
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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