Life Beneﬁt Claim Form
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Group #: Certiﬁcate or Social Security #:
Name of Deceased: Relationship to Insured:
Residence at Time of Death: Cause of Death:
Date of Death:
___/___/___ (MM/ DD/YYYY) Place of Death:
Date of Birth:
___/___/___ (MM/ DD/YYYY) Place of Birth:
Any person who knowingly and 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. (I.C. § 35-43-5-3.5)
AUTHORIZATION TO OBTAIN INFORMATION
This is an authorization under the Privacy Rules of the Health Insurance Portability and Accountability Act of 1996 [45 CFR §164.5080].
This is your authority to allow the bearer hereof, who is acting on behalf of International Medical Group, to examine or copy any and all records,
reports, correspondence, medical bills, medical reports, claim information, payout information, referral requests, and approvals regarding
the person named below, under the insurance certiﬁcate number _____________, insured ID # _____________, DOB __________ and policy
holder ___________ .
The cost of any copies or reports shall be at the expense of International Medical Group. A reproduction of this authorization shall be considered as
good and valid as the original.
Dated this _____________ day of __________________________ , 20________ .
State of _________________ SS: _______________________________________________
Country of _____________
Before me, a Notary Public, in and for said County and State, personally appeared, _________________________________________________ ,
who acknowledged the execution of the foregoing, and who ﬁrst being duly sworn, stated that the facts contained herein are true.
Witness my hand and seal this _______ day of ________________ , 200 ________ .
My Commission Expires: ____________ My Country of Residence is: ____________________________________________________________
Personally known ______ OR Produced identiﬁcation ______ Type of identiﬁcation produced ________________________________________
This form is to be completed by the person or persons to whom the policy beneﬁts are legally payable as beneﬁciary under the terms
of the Certiﬁcate. If the beneﬁciary is the insured’s estate, the statement should be completed by the executor or administrator and
a certiﬁed copy of the appointment issued by the proper court should be attached. If the beneﬁciary is not of legal age, a guardian
or custodial parent must also sign this document.
Please print legibly and complete ALL SECTIONS of this form. Mail, fax, or email completed form to:
Address: International Medical Group, Inc. Claims, P.O. Box 9162, Farmington Hills, MI 48333-9162 USA,
Call: +1.800.628.4664 or outside U.S. +1.317.655.4500; Fax: +1.317.655.4505