Globe Life And Accident Insurance Company
Insurance Services Division P.O. Box 8076 • McKinney, Te
xas 75070
DISABILITY/WAIVER OF PREMIUM CLAIMANT’S STATEMENT
Please carefully read all of the following information before completing this statement.
Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and
confinement in state prison.
Arkansas, Louisiana, Rhode Island, Texas and West Virginia: 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.
Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false,
incomplete, or misleading information may be prosecuted under state law.
Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a
false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
California: For your protection California law requires that you be made aware of the following: 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 a state prison.
Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the
purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil
damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or
information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard
to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the department of
regulatory agencies.
District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the
insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false
information materially related to a claim was provided by the applicant.
Florida: Any person who knowingly or with intent to injure, defraud or deceive any insurer files a statement of claim or an application
containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Hawaii: For your protection, Hawaii law requires you to be informed that any person who presents a fraudulent claim for payment of a loss
or benefit is guilty of a crime punishable by fines or imprisonment, or both.
Idaho: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing any
false, incomplete or misleading information is guilty of a felony.
Indiana: Any person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or
misleading information commits a felony.
Kentucky: Any person who knowingly or with intent to defraud any insurance company or other person files a 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.
Maine: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
Minnesota: Any person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilt of a crime.
New Hampshire: Any person who, with a purpose to inure, defraud or deceive any insurance company, files a statement of claim
containing any false incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in
RSA 638.20.
New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and
civil penalties.
New Mexico: 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 civil fines and criminal penalties.
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.
Oklahoma: WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer, makes any claim for the
proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Oregon: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents materially
false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.
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.
Tennessee, Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
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Globe Life And Accident Insurance Company
Insurance Services Division • P.O. Box 8076 • McKinney, Texas 75070
DISABILITY/WAIVER OF PREMIUM — CLAIMANT’S STATEMENT
Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject
to fines and confinement in state prison.
Insured’s Name: _____________________________________________________________________ Policy Numbers:________________________________________________________
Address: ________________________________________________________________________________________________________________________________________________________
Street
City
S
ta
te ZIP
Social Security #: ______________________________________ Date of Birth: ____________________
Age: ________
__ Height: ___________
Weight: _____________
Phone: Home ______________________________________ Work: ____________________________________ Email Address: ________________________________________________
HISTORY
1. Describe your present illness or injury fully: _____________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
2. When did this illness or injury begin (date)? ____________________________________________________________________________________________
3. Have you had this illness or injury or one similar to it before? Yes No If Yes, when (date)?___________________________________
4. Please provide names and addresses of all physicians you have seen due to this condition:
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
5. Have you been confined to a hospital as a result of this illness or injury? Yes No If Yes, please provide the name and
address of the hospital and the date(s) of confinement:
___________________________________________________________________________________________________________________________________________
6. Have you filed for Social Security Disability? Yes No
If Yes, please submit a copy of either your award or denial letter.
If you were denied, are you appealing the decision? Yes No
EMPLOYMENT
1. Name, address, & phone number of your employer when you became unable to work: ______________________________________________
___________________________________________________________________________________________________________________________________________
2. How long did you work for this employer? _____________________________________________________________________________________________
3. Name of immediate supervisor: _________________________________________________________________________________________________________
4. What was your occupation?_____________________________________________________________________________________________________________
5. When did this illness or injury cause you to cease work (date)?_________________________________________________________________________
6. Is this injury or illness the result of your employment? Yes No Unknown If “Yes”, have you filed a claim for Workmen’s
Compensation? Please provide the name and address of Workmen’s Compensation Carrier
___________________________________________________________________________________________________________________________________________
Signature of Insured: __________________________________________________________________________
Date:____________________________________________________
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signature
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ATTENDING PHYSICIAN’S STATEMENT OF DISABILITY
Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may
be subject to fines and confinement in state prison.
Address: ________________________________________________________________________________________________________________________________________________________
Street, City, State, ZIP
DIAGNOSIS
1. Diagnosis:___________________________________________________________ 2. Date of diagnosis: Month ___________ Day _____ Year _________
3. Subjective symptoms: _____________________________________________________________________________________________________________________
4. Objective findings (including current X-Rays, EKG’s, Lab Data and any other clinical findings):
_____________________________________________________________________________________________________________________________________________
5. Is there a previous history of this illness or injury? Yes No If Yes, state when & describe:
_____________________________________________________________________________________________________________________________________________
PROGRESS
Recovered? Improved? Unchanged? Retrogressed?
Ambulatory? House confined? Bed confined?
Hospital confined?
1. Has patient:
2. Is patient:
3. Has patient been hospital confined? Yes No If “Yes”, give name and address of hospital:
_____________________________________________________________________________________________________________________________________________
4. Dates of confinement:
Admitted: Month ______ Day _____ Year ____________ Discharged: Month ______ Day _____ Year ____________
PHYSICAL IMPAIRMENT
PROGNOSIS
Patient
s Job
Any Other Work
Yes No
Yes No
Yes No
Yes No
1. Is patient now totally disabled?
2. Do you expect a marked change in the future?
a) If “Yes”, when will patient recover sufficiently to perform duties?
b) If “No”, please explain:
Physician's Name (PRINT)
Physician’s Signature Phone Number Fax Number
Insured's Name: ________________________________________________ Date of Birth: _____________________ Policy Numbers: ________________________________________
Street Address City State Zip Code
_______________________________________________________________________
___________________________________________________________________________________________________________________
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Class 1 - no limitation; capable of heavy activity (0-10%) Class 2 - slight limitation; capable of light activity (15-30%)
Class 3 - moderate limitation; capable of sedentary activity (35-55%) Class 4 - marked limitation (60-70%)
Class 5 - severe limitation; incapable of sedentary activity (75-100%)
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AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
Insured's Name: Date of Birth:
Social Security Number: Policy Number:
Insured's Address:
Authority to sign on behalf of patient:
Parent
Child
Legal Guardian
Spouse
Other (please specify relationship to insured): ___________________________________________________________________________
Name of person signing form: _________________________________________________________________________________________________
Name and address of person(s) or category of person to whom this information will be sent:
Globe Life And Accident Insurance Company
PO Box 8076
McKinney, TX 75070
I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, pharmacy benefit manager, medical
facility, other insurance company, consumer reporting agency, Medical Information Bureau (MIB), or other health care provider that has
provided payment, treatment or services to me or on my behalf ("My Providers") to disclose my entire medical record and any other
protected health information concerning me to the below named entity and its agents, employees, and representatives. This includes
information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases. This also
includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and tobacco; but excludes psychotherapy
notes.
By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply to this
authorization and I instruct any physician, health care professional, hospital, clinic, medical facility, or other health care provider to release and
disclose my entire medical record without restriction.
This protected health information is to be disclosed under this authorization in order to: 1) administer claims and determine or fulfill
responsibility for coverage and provision of benefits; 2) administer coverage; and 3) conduct other legally permissible activities that
relate to any coverage I have or have applied for.
This authorization shall remain in force for 24 months following the date of my signature below, and a copy of this authorization is as valid as
the original. I understand that I have the right to revoke this authorization in writing, at any time, by sending a written request for revocation
to the entity named below at the address also listed. I understand that a revocation is not effective to the extent that any of My Providers has
relied on this authorization or to the extent that the named entity has a legal right to contest a claim under an insurance policy or to contest
the policy itself. I understand that any information that is disclosed pursuant to this authorization may be re-disclosed and no longer covered
by federal rules governing privacy and confidentiality of health information.
I understand that My Providers may not refuse to provide treatment or payment for health care services if I refuse to sign this authorization. I
further understand that if I refuse to sign this authorization to release my complete medical record, GL may not be able to process my claim
or make any benefit payments. I have received a copy of this authorization.
IMPORTANT: If the patient is deceased, please INITIAL on of the statements below:
_____I am the Administrator/Executor for the deceased and Letters of Testamentary, Executor of Estate documents, or other comparable
documentation is enclosed.
_____There is no court appointed Administrator/Executor and I am the Next of Kin.
All items on this form have been completed and my questions about this form have been answered, and I have been provided a copy of this
form.
Signature of patient or personal representative: ___________________________________________ Date Signed: ________________________________________
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Next of Kin
Executor of Estate
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