Fillable INSTRUCTIONS Accelerated Death Claim Form Your Life Insurance (University of Texas System)

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INSTRUCTIONS Accelerated Death Claim Form Your Life Insurance (University of Texas System)

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Return to Blue Cross and Blue Shield of Texas at:
Attention: Claims Department
P.O. Box 7070
Downers Grove, IL 60515
Phone Number: (866) 628-2606
Fax: (312) 540-4706
Accelerated Death Claim Form
R040119 |
Z6296_TX_UT
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life
Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service
marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
Page 1 of 8
INSTRUCTIONS
Your Life Insurance policy allows you to apply for an accelerated benefit paid to you during your lifetime if you are
determined to have a terminal illness. This benefit is an advance payment of a portion of your Life Insurance, up to
the maximum amount indicated in your Life Insurance policy. If your claim is approved and payment is made to you
the amount of your Life Insurance under the Group Policy will be reduced by the Benefit paid.
To apply, the Claim packet should be completed in full. Each entry is important and must be completed to avoid delay
in processing your claim. If an information block does not apply or if information is not available, please write “none” in
the space provided. If a form is incomplete, it will be returned. PLEASE PRINT.
To be eligible for this Benefit, you must meet the following conditions:
• Be insured for Life Insurance under the Group Policy at the time you apply and receive this benefit.
• Provide us with satisfactory written proof from a medical professional that you have a terminal illness.
Please note that you can receive this benefit only once.
Your claim packet consists of:
Section 1, Parts A & B, Employee Statement
Section 1, parts A & B are to be completed by the Employee and returned to the Employer to be sent to Blue Cross
and Blue Shield of
Texas (BCBSTX). Remember to sign and date each Statement. Your signature enables
BCBSTX to obtain the information necessary to determine your eligibility for this benefit. You may request a copy of
this authorization.
Section 2. Employer Statement
To be completed by the Employer and returned to BCBSTX along with Section 1. Sections 1 & 2 should be sent to
BCBSTX as soon as they are completed, and the Attending Physician Statement can be sent at a later date.
Section 3, Attending Physician Statement
To be completed by the Employee’s Physician. If you have more than one Physician for your condition, a statement
should be completed by each Physician. The completed section of the claim form should be returned to:
Blue Cross and Blue Shield of Texas
Attention Claims Department
P.O. Box 7070
Downers Grove, IL 60515
The Employee is responsible for ensuring that all required portions of the claim form are completed and returned to
BCBSTX. Contact
BCBSTX at 866-628-2606 for any questions or assistance regarding this claim form packet.
Return to Blue Cross and Blue Shield of Texas at:
Attention: Claims Department
P.O. Box 7070
Downers Grove, IL 60515
Phone Number: (866) 628-2606
Fax: (312) 540-4706
Accelerated Death Claim Form
R040119 |
Z6296_TX_UT
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life
Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service
marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
Page 2 of 8
SECTION 1 -
PART A – TO BE COMPLETED BY THE EMPLOYEE
Receipt of accelerated death benefits may affect eligibility for public assistance programs such as medical
assistance (Medicaid), aid to families with dependent children and supplemental security income. Receipt of
accelerated death benefits in periodic payments may be treated differently than receipt in a lump sum. Prior
to applying for accelerated death benefits, you should consult with the appropriate social services agency
concerning how receipt will affect your eligibility and/or that of your spouse or dependents.
Receipt of accelerated death benefits may be taxable. Receipt of accelerated death benefits in periodic
payments may be treated differently than receipt in a lump sum. Prior to applying for such benefits, you should
seek assistance from a qualified tax advisor.
No health care facility as defined in Section 20 of the Public Health Law can require you to accelerate payment of a
death benefit as a condition of admission to such health care facility or for providing any care in such facility.
BCBSTX is prohibited from paying accelerated death benefits to you for a period of 14 days from the date of your
application for an Accelerated Death Benefit.
This application is voluntary and without coercion on the part of any third party.
Your spouse is required to sign this request if you reside in one of the Following Community Property states: Arizona,
California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington or Wisconsin.
Date
Signature
Print Name
Date Spouse Signature
Print Name
Return to Blue Cross and Blue Shield of Texas at:
Attention: Claims Department
P.O. Box 7070
Downers Grove, IL 60515
Phone Number: (866) 628-2606
Fax: (312) 540-4706
Accelerated Death Claim Form
R040119 |
Z6296_TX_UT
Insurance products issued by Dearborn Life Insurance Company, 701
E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life
Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service
marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
Page 3 of 8
SECTION 1 PART B – TO BE COMPLETED BY THE EMPLOYEE
Claimant’s Name
Address
5. Have you ever had a similar illness:
If yes, give dates
Dates confined
Address of Hospital(s)
Last First Middle
Date of Birth Social Security No. HT WT
Street City State Zip
Phone E-mail
OccupationName of Employer
Maiden Name
1. Date of accident or beginning of sickness
NoYes
2. Are you still working:
If No, Date last worked
3. Nature of injury or illness
4. If injury, describe how,
when and where accident
occurred
Yes No
From To
6. Name of Hospital(s) - Attach separate page if necessary
To
From
Street City
Zip
State
Dates of treatment
Address of Doctor(s)
7. Name of Doctor(s) - Attach separate page if necessary
To
From
Street City
Zip
State
8. If benefits are being claimed for a dependent spous
e or child, complete the following
Dependent Name Social Security Number
Date of Birth Gender Relationship
9. BCBSTX benefits being claimed
Amount of Life Insurance Inforce $
Amount of Benefit Requested $
Remaining Life Insurance $
Return to Blue Cross and Blue Shield of Texas at:
Attention: Claims Department
P.O. Box 7070
Downers Grove, IL 60515
Phone Number: (866) 628-2606
Fax: (312) 540-4706
Accelerated Death Claim Form
R040119 |
Z6296_TX_UT
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life
Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service
marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
Page 4 of 8
Section 2 : EMPLOYER’S/PLAN ADMINISTRATOR’S STATEMENT
Employer’s Address
%
If injured party is a dependent spouse or child, complete the following
I certify that I have read this document and the information is accurate and complete. I understand that any
person who knowingly files a statement of claim containing any false or misleading information is subject to
criminal and civil penalties.
Employee's Name
Last First Middle
Social Security No.
Hire Date Insured Effective Date
Zip
StateCityStreet
Employer's E-mail Address
Last Day Worked Date Returned Base Annual Salary
Hours Worked per Week
Workers' Comp Claim Filed
Employee's Occupation
Premium Contributation by Employer
Employee
%
Employee Contribution pre-tax?
Yes No
Amount of Life Insurance Inforce
Dependent's
Name
Last First Middle
Social Security No.
Relationship to Employee
Amount of Benefit Requested $
Remaining Life Insurance $
Date of Birth Gender
BCBSTX
Benefits being claimed Amount of Life Insurance Inforce $
Date
Signature of Authorized Employer/Plan Representative
Print Name
Return to Blue Cross and Blue Shield of Texas at:
Attention: Claims Department
P.O.
Box 7070
Downers Grove, IL 60515
Phone Number: (866) 628-2606
Fax: (312) 540-4706
Accelerated Death Claim Form
R040119 |
Z6296_TX_UT
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life
Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service
marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
Page 5 of 8
Section 3 – Attending Physician’s Statement
Dear Doctor:
The purpose of this report is to assist us in evaluating the patient’s claim for payment of an accelerated life insurance
benefit for terminal illness. In completing this report, please include sufficient details of history, physical or diagnostic
findings, clinical course, therapy and response to therapy so that we are able to complete our evaluation.
THE PATIENT IS RESPONSIBLE FOR ANY EXPENSE INVOLVED IN THE COMPLETION OF THIS FORM.
DIAGNOSIS
Please submit, with completed form, copies of all objective findings (including current test findings, x-ray reports, EKG’s.
Laboratory Data and clinical findings.)
HISTORY
NATURE AND DATES OF TREATMENT (Including medications prescribed)
SURGICAL PROCEDURES AND DATES
If confined to a hospital or other facility, provide name, address and dates of confinement:
PROGNOSIS
PATIENT NAME
Last First Middle
EMPLOYEE NAME IF OTHER
THAN PATIENT
Last First Middle
Date of last examination
Diagnosis (including any
complications)
ICD-9 Code(s)
When did the symptoms first appear or accident happen
Date first seen for this condition
Was patient referred by another physician:
Yes No
Address
Referring physician's name
Phone
Street City
Zip
State
Email
Yes No
Have You Diagnosed this Patient as Terminally Ill:
Date First Diagnosed as Terminally Ill
Anticipated Life Expectancy
Physician Name Specialty
Physician Signature
ZipStateCityStreet
Address
Return to Blue Cross and Blue Shield of Texas at:
Attention: Claims Department
P.O. Box 7070
Downers Grove, IL 60515
Phone Number: (866) 628-2606
Fax: (312) 540-4706
Accelerated Death Claim Form
R040119 |
Z6296_TX_UT
Insurance products issued by Dearborn Life Insurance Company, 701
E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life
Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service
marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
Page 6 of 8
AUTHORIZATION FOR RELEASE OF INFORMATION
I (the undersigned) authorize any physician, medical professional, pharmacist or other provider of health care
services, hospital, clinic, other medical or medically related facility; coroner’s office; insurance or reinsurance
company;government agency; department of labor; law enforcement or public safety department; group policyholder;
employer;or policy or benefit plan administrator to release information from the records of:
Claimant/Insured Information to be released:
• Data or records regarding medical history, treatment, prescriptions, consultations, autopsy (including
medical and psychological reports; records, charts, notes – excluding psychoth
erapy notes -, x-rays, films
or correspondence, and any medical condition(s));
• Any information regarding insurance coverage; and
• Accident report or any official investigative reports (such as police, fire, FAA, OSHA, or toxicology report).
• Information to be released to: Blue Cross and Blue Shield of Texas
P.O. Box 7070
Downers Grove, IL 60515
• I understand the information obtained by use of t
his Authorization will be used by Blue Cross and Blue
Shield of Texas (BCBSTX) to evaluate my claim for death benefits. The Company will only release such
information:
- To its reinsurer, or other persons or organizations performing business or legal services in
connection with my claim(s); or
- As otherwise may be required by law or as I further authorize.
I further understand that refusal to sign this Authorization may result in the denial of benefits.
• I understand the information used or disclosed may be subject to re-disclosure by the recipient and may
no longer be protected by federal law.
• I understand that I may revoke this Authorization in writing at any time, except to the extent;
- The Company has taken action in reliance on this Authorization; or
- The Company is using this Authorization in connection with a contestable claim.
If written revocation is not received, this Authorization will be considered valid for a period of time not to
exceed 24 months from the date of signature below. To initiate revocation of this Authorization, direct all
correspondence to the company at the above address.
• A photocopy of this Authorization is to be considered as valid as the original.
• I understand I am entitled to receive a copy of this Authorization.
Claimant/Legal representative (Nearest relative, legal guardian, or appointed representative to sign only if claimant/
insured is a minor, legally incompetent, or deceased.) Power of attorney or guardianship must be attached.
Date of Birth
MiddleFirstLast
Claimant/Insured
Name
DateSignature
Print Name
Relationship to Claimant/Insured or personal/legal representative signing for Claimant/Insured:
ZipStateCityStreet
Email
Address
Phone
Administrative Office: 701 E. 22nd Street, Lombard, IL 60148
Fraud Notices
The laws of some states require us to furnish you with the following notice:
R040119 I Z6291_LC
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cr
oss and Blue Shield of Texas is the trade name of Dearborn Life
Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service
marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
Page 7 of 8
Maryland: Any person who knowingly and willingly presents
a false or fraudulent claim for payment of a loss or benefit or
who knowingly and willfully presents false information in an
application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
Virginia: 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.
FOR APPLICATIONS AND CLAIMS:
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 and 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 be
informed that presenting a fraudulent claim for payment of a
loss or benefit is a crime punishable by fines or
imprisonment, or both.
Kentucky: Any person who knowingly and with intent to
defraud any insurance company or other person files an
application for insurance or 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.
Louisiana: 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.
Maine & 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.
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
knowingly 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: Any person who knowingly, with intent to
injure, defraud or deceive any insurer, makes a claim for
the proceeds of an insurance policy containing false,
incomplete or misleading information is guilty of a felony.
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.
Puerto Rico: Any person who knowingly and with the
intention of defrauding presents false information in an
insurance application, or presents, helps, or causes the
presentation of a fraudulent claim for the payment of a
loss or any other benefit, or presents more than one claim
for the same damage or loss, shall incur a felony and,
upon conviction, shall be sanctioned for each violation
with the penalty of a fine of not less than five thousand
dollars($5,000) and not more than ten thousand dollars
($10,000), or a fixed term of imprisonment for three (3)
years, or both penalties. Should aggravating
circumstances be present, the penalty thus established
may be increased to a maximum of five (5) years, if
extenuating circumstances are present, it may be reduced
to a minimum of two (2) years.
Rhode Island: 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.
Tennessee: 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.
Alabama: Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benefit or who
knowingly presents false information in an application
for insurance is guilty of a crime and may be subject
to restitution fines or confinement in prison, or any
combination thereof.
Administrative Office:
701 E. 22nd Street, Lombard, IL 60148
Fraud Notices
The laws of some states require us to furnish you with the following notice:
R040119 I Z6291_LC
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cr
oss and Blue Shield of Texas is the trade name of Dearborn Life
Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service
marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
Page 8 of 8
FOR CLAIMS ONLY:
Idaho: Any person who knowingly, and with intent
to defraud or deceive any insurance company,
files a statement or claim containing false,
incomplete, or misleading information is guilty of a
felony.
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.
Arkansas: 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.
California: For your protection California law
requires the following to appear on this form. Any
person who knowingly presents false or fraudulent
claim for the payment of a loss is guilty of a crime
and may be subject to fines and confinement in
state prison.
Delaware: Any person who knowingly, and with
intent to injure, defraud or deceive any insurer,
files a statement of claim containing any false,
incomplete or misleading information is guilty of a
felony.
Indiana: A 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.
Minnesota: A person who files a claim with intent to
defraud or helps commit a fraud against an insurer
is guilty of a crime.
New Hampshire: Any person who, with a
purpose to injure, 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.
Texas: 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 state prison.
Massachusetts: 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.
FOR APPLICATIONS ONLY:
New Jersey: Any person who includes any
false or misleading information on an
application for an insurance policy is subject to
criminal and civil penalties.
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INSTRUCTIONS Accelerated Death Claim Form Your Life Insurance (University of Texas System)

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Completed 13 January 2021

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