Fillable GUARD Berkshire Hathaway Insurance Companies DISABILITY BENEFITS DB (Berkshire Hathaway GUARD Insurance Companies)

Fill Online, Printable, Fillable, Blank GUARD Berkshire Hathaway Insurance Companies DISABILITY BENEFITS DB (Berkshire Hathaway GUARD Insurance Companies) Form

Use Fill to complete blank online BERKSHIRE HATHAWAY GUARD INSURANCE COMPANIES pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

GUARD Berkshire Hathaway Insurance Companies DISABILITY BENEFITS DB (Berkshire Hathaway GUARD Insurance Companies)

On average this form takes 2 minutes to complete

The GUARD Berkshire Hathaway Insurance Companies DISABILITY BENEFITS DB (Berkshire Hathaway GUARD Insurance Companies) form is 5 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 6 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Berkshire Hathaway GUARD Insurance Companies forms online.

BROWSE BERKSHIRE HATHAWAY GUARD INSURANCE COMPANIES FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
DISABILITY BENEFITS
DB 99 10 05 07 11
DB 99 10 05 07 11 AmGUARD Insurance Company Page 1 of 5
P.O. Box 1368 • Wilkes-Barre, PA 18703-1368 • www.guard.com
GUARD
Berkshire Hathaway
Companies
Insurance
NEW YORK DISABILITY BENEFITS LAW (DBL) INSURANCE POLICY
ACCIDENTAL DEATH & DISMEMBERMENT CLAIM FORM
All pages must be completed for claim processing.
I. GENERAL INFORMATION (EMPLOYER COMPLETES)
1. Employer (Business Name): ________________________________________________________________
a. Policy No.: _______________________________________________________________________
b. Business Address: __________________________________________________________________
_________________________________________________________________________________
c. Name of Authorized Representative: ____________________________________________________
d. Title:_____________________________________________________________________________
e. Phone: _________________________________________________________________________
f. Contact E-mail: ____________________________________________________________________
2. Deceased/Injured Employee (Last, First, Middle Initial): ___________________________________________
a. Address: _________________________________________________________________________
_________________________________________________________________________________
b. Phone: ___________________________________________________________________________
c. Occupation: _______________________________________________________________________
d. Date Hired: ________________________________________________________________________
e. Date Last Worked: __________________________________________________________________
f. Date Returned to Work (if applicable): __________________________________________________
g. Date of Birth: ______________________________________________________________________
h. Social Security No.: _________________________________________________________________
______________________________________________________ _____________________________
Signature of Employer’s Authorized Representative Date
Upon completion, be sure to sign and date this form before submitting to us.
DISABILITY BENEFITS LAW (DBL) COVERAGE
DB 99 10 05 07 11 AmGUARD Insurance Company Page 2 of 5
P.O. Box 1368 • Wilkes-Barre, PA 18703-1368 • www.guard.com
II. ACCIDENT CIRCUMSTANCES (EMPLOYEE COMPLETES; EMPLOYER COMPLETES IN EVENT OF DEATH)
Did this accident happen on the job or did it arise out of/in the course of employment? __ Yes __ No
Has this claim been considered in connection with a Workers’ Compensation claim? __ Yes __ No
If yes, what is the status of the claim? ____________________________________________________________
Date/Time of Accident: ________________________________________________________________________
Place of Accident (City, State): __________________________________________________________________
Describe all injuries received:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Describe in detail how the accident happened:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Name and address of law enforcement agency involved (Please submit copy of Police Report and/or Case No.):
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
List name/address/phone number of all physicians consulted regarding this death/injury:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
List name/address/phone number of all hospitals consulted regarding this death/injury:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
DISABILITY BENEFITS LAW (DBL) COVERAGE
DB 99 10 05 07 11 AmGUARD Insurance Company Page 3 of 5
P.O. Box 1368 • Wilkes-Barre, PA 18703-1368 • www.guard.com
Did/Does the deceased/injured have any chronic disease or physical defect/deformity? __ Yes __ No
Did the accident result in death? __ Yes __ No
If yes, on what date? ______________________________________________________________________
Was deceased an active, eligible employee at the time of death? __ Yes __ No
Was autopsy performed? __ Yes __ No
If yes, provide name/address/phone number of coroner or copy of autopsy report:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Was an inquest held? __ Yes __ No
If yes, verdict: ____________________________________________________________________
*Beneficiary: AD&D death benefits under the DBL Rider are payable to estate of the deceased. All other
benefits are paid to the injured employee.*
NOTICE: 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 factual
material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to
a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation.
In what capacity are you making the claim? ____________________________________________________
If other than injured employee (or Employer’s Authorized Representative in event of death), attach
appropriate legal documents. Your relationship to injured employee: ________________________________
I authorize any physician, medical professional, hospital, covered entity as defined under HIPAA, insurer, or
other organization or person having any records, dates, or information concerning the deceased or injured’s
occupation, finances; and health (including protected information, individually identifiable health information,
summary health information, psychotherapy notes, mental health, HIV, and alcohol/drug records) to release
all such records in their entirety to AmGUARD Insurance Company and any affiliate (collectively and severally,
the “Company”). I understand that I may receive a copy of this authorization, that this authorization is valid
for the entire duration of this claim, and that I may revoke this authorization at any time by sending a request
in writing to the Company. I understand that it may be necessary for the Company to provide such
information or summaries thereof to the employer, regulatory state agency, other insurance company, or
Workers’ Compensation carrier.
______________________________________________________ _____________________________
Signature of Injured Employee Date
______________________________________________________ _____________________________
Signature of Employer’s Authorized Representative Date
(In event of death)
______________________________________________________ _____________________________
Signature of Other Representative Date
Upon completion, be sure to sign and date this form before submitting to us.
DISABILITY BENEFITS LAW (DBL) COVERAGE
DB 99 10 05 07 11 AmGUARD Insurance Company Page 4 of 5
P.O. Box 1368 • Wilkes-Barre, PA 18703-1368 • www.guard.com
III.ATTENDING PHYSICIAN’S STATEMENT (PHYSICIAN COMPLETES, SIGNATURE REQUIRED)
MEDICAL RECORDS MUST BE SUBMITTED TO SUPPORT CLAIM
Patient’s Name: __________________________________________________________________________
Date of Birth: ______________________________ Social Security No.: _____________________________
Date of Injury: _________________ Date of first visit: ______________
Date of Last Visit: _______________ Frequency: __ weekly __ monthly __ other ____________________
Had patient previously received medical attention for this injury? ___ Yes ___ No
If yes, prescribed by whom? __________________________________________________________
Objective findings (EKG’s, x-rays, lab data, clinical findings): ______________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Symptoms: ______________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Diagnosis: _______________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
What complications have arisen, if any? ______________________________________________________
________________________________________________________________________________________
Was patient under the influence of alcohol and/or other prescription or non-prescription drugs or other
substances at the time of accident/injury? ____ Yes ____ No ____ Unknown
Is condition due to injury/sickness arising out of patient’s employment?____Yes ____ No ____Unknown
Nature of treatment (type of surgery, medications): ______________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Date of surgery: __________________________________________________________________________
Has patient been hospital confined? ____ Yes ____ No
Hospital stay from ______________ through ______________
Name and address of hospital: _______________________________________________________________
________________________________________________________________________________________
Name of surgeon: _________________________________________________________________________
List name/address/phone number of all other treating physicians: ___________________________________
________________________________________________________________________________________
Patient’s condition: __ Recovered __ Improved __ Unchanged __ Retrogressed
Patient is: __ Ambulatory __ Bed confined __ House confined __ Hospital confined __ Hospice
DISABILITY BENEFITS LAW (DBL) COVERAGE
DB 99 10 05 07 11 AmGUARD Insurance Company Page 5 of 5
P.O. Box 1368 • Wilkes-Barre, PA 18703-1368 • www.guard.com
LOSS OF LIMB? Yes _____ No ______ If yes, please answer the following:
1. Did insured lose limb as a result of said accident? Yes _____ No _____
2. If Yes, please mark applicable loss(es):
a) Left Wrist: ___ Above ___ Below
b) Left Arm: ___ Above Elbow ___ Below Elbow
c) Left Foot: ___ Above ___ Below
d) Left Leg: ___ Above Knee ___ Below Knee
e) Right Wrist: ___ Above ___ Below
f) Right Arm: ___ Above Elbow ___ Below Elbow
g) Right Foot: ___ Above ___ Below
h) Right Leg: ___ Above Knee ___ Below Knee
3. Date of amputation: ____ / ____ / ______
4. If amputation was necessary, was the injury, of itself and independent of all other causes, sufficient to
require amputation? _____ Yes _____ No
LOSS OF SIGHT? Yes _____ No _____ If yes, please answer the following:
1. Did insured lose sight as a result of said accident? Yes _____ No _____
2. If totally blind, provide the date this occurred:
Right Eye ___ / ___ / _____ Left Eye ___ / ___ / _____
3. If eye has been enucleated, provide date:
Right Eye ___ / ___ / _____ Left Eye ___ / ___ / _____
4. In your opinion, can vision be improved by treatment, operation, or lenses?
Yes _____ No ______
Recommendations: ___________________________________________________________
5. Is loss of sight irrecoverable? Yes _____ No _____
6. Was there any disease or condition prior to the date of the accident, which might have served as a
contributory cause? Yes ____ No _____
RECORD OF VISION
Date of FIRST observation: ___/____ /_____ Date of LAST observation: ____ / ____ / _____
Uncorrected Right Eye: __________ Uncorrected Right Eye: __________
Uncorrected Left Eye: __________ Uncorrected Left Eye: __________
Corrected Right Eye: __________ Corrected Right Eye: __________
Corrected Left Eye: __________ Corrected Left Eye: __________
Physician Name: ________________________________________________________________________________
Address: ______________________________________________________________________________________
______________________________________________________________________________________________
Phone: ____________________________ Email: ___________________________________________________
Tax ID: _______________________ Physician’s Specialty/Degree: ________________________________________
______________________________________________________ _____________________________________
Signature of Physician Date
Upon completion, be sure to sign and date this form before submitting to us.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

GUARD Berkshire Hathaway Insurance Companies DISABILITY BENEFITS DB (Berkshire Hathaway GUARD Insurance Companies)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 9 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document