DISABILITY BENEFITS
DB 99 10 04 07 11
DB 99 10 04 07 11 AmGUARD Insurance Company Page 1 of 1
P.O. Box 1368 • Wilkes-Barre, PA 18703-1368 • www.guard.com
GUARD
Berkshire Hathaway
Companies
Insurance
NEW YORK STATE DISABILITY BENEFITS LAW (DBL) INSURANCE POLICY
IN-HOSPITAL STATEMENT OF CLAIM
Complete this form and return to:
AmGUARD Insurance Company
P.O. Box 1368
Wilkes-Barre, PA 18703-1368
I. TO BE COMPLETED BY INSURED
Name: _______________________________________ Employed By: _____________________________________
Address: ______________________________________________________________________________________
Birth Date: ______________________________ Sex: __________ SSN: ________________________________
Admission Date: ______________________________ Discharge Date: ___________________________________
REQUIRED STATEMENT: “Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance containing false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.”
I authorize any individual or organization to release any information to AmGUARD Insurance Company for any
services or benefits received or payable to me or on my behalf.
II. TO BE COMPLETED BY HOSPITAL
Name of Hospital: _______________________________________________________________________________
Location: ______________________________________________________________________________________
Patient: _______________________________________________________________________________________
Age: ______________________ Sex: _____ If minor, name of guardian: ___________________________________
Admitted (Date): ______________________________ Discharged (Date): _________________________________
Total Days Hospitalized: ______________________
Was patient in Intensive Care Unit during hospitalization? _____ Yes _____ No
If yes, furnish dates of such I.C.U. confinement: From __________________ To ______________________
If patient is still hospitalized, please indicate expected duration of current hospitalization _______________________
Diagnosis: _____________________________________________________________________________________
___________________________________________________ ________________________
Signature of Medical Records Librarian or Authorized Designee Date
Upon completion, be sure to have the form signed and dated before submitting to us.
