Fillable Life-ins-claim-rsl Proof of Loss Claim Statement

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Life-ins-claim-rsl Proof of Loss Claim Statement

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EF-1205
IMPORTANT INFORMATION REGARDING APPLICATION FOR BENEFITS
This form is to be attached to the proof of Loss Claim Statement when a claim is submitted to
Reliance Standard Life. Please be sure that all responsible parties completing and filing a claim
for benefits are aware of the following statements which concern claim fraud and abuse:
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.
State of California
For your protection, California law requires the following to appear on this form: 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.
State of Florida
Any person who knowingly and with intent to injure, defraud, or deceive any insurer, files a
statement of claim or an application containing false, incomplete or misleading information is
guilty of a felony of the third degree.
State of New Jersey
Any person who knowingly files a statement of claim containing any false or misleading
information is subject to criminal and civil penalties.
State of New York
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 shall also be subject to a civil
penalty not to exceed five thousand dollars and the stated value of the claim for each such
violation.
State of Ohio
Any person who, with intent to defraud or knowing that he is facilitatingafraudagainstan
insurer, submits an application or files a claim containing a false or deceptive statement is guilty
of insurance fraud.
State of Oregon
Any person who, with an intent to knowingly 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, may be subject to prosecution for insurance fraud.
State of 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.
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P.O. Box 7307
Philadelphia, PA 19101-7307
EF-1025
LIFE CLAIM AUTHORIZATION FOR USE IN OBTAINING INFORMATION
NAME OF DECEDENT: ________________________________________________
DECEDENT’S DATE OF BIRTH: _________________________________________
DATE OF DEATH: ___________________________________________________
BENEFICIARY: ___________________________________________________
NEXT OF KIN OR LEGAL REPRESENTATIVE OF
DECEDENT’S ESTATE: _________________________________________________
RELATIONSHIP: __________________________________________________
(If Executor, Administrator etc., Provide Appropriate Court Order)
To all physicians and other health care professionals, hospitals, other health care institutions, insurers,
medical, hospital and prepaid health plans, pharmacies, pharmacy benefit managers, employers, group
policyholders, contract holders, governmental agencies (including but not limited to the Internal Revenue
Service and the Social Security Administration), private and/or public benefit plan administrators, and/or
attorney representatives, including but not limited to covered entities and business associates under the
Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the accompanying regulations:
You are authorized to provide Reliance Standard Life Insurance Company and/or its authorized
administrators with information concerning medical care, advice, and/or treatment provided to the above
named Decedent, and/or any employment, salary and/or benefit-related information concerning the
above named Decedent. I understand that the disclosure of information may include disclosure of
protected health information under HIPAA and the accompanying regulations, information regarding
treatment for mental illness, the human immunodeficiency virus (HIV) and/or the use of drugs and
alcohol. I also understand that information used or disclosed pursuant to this authorization may be
subject to redisclosure by the recipient and will no longer be subject to protection under HIPAA and the
accompanying regulations. A statement of Reliance Standard Life Insurance Company’s privacy policy is
available at
www.rsli.com or upon request.
I understand that any such information will be used for the purpose of evaluating my claim for benefits.
Upon request, I understand that I am entitled to receive a copy of this Authorization. This Authorization is
valid from the date signed for the duration of the claim, and may be revoked by me at any time upon
written request to the address below. A reproduction of this Authorization shall be considered as valid as
the original.
________________________ ________________________________
Date Beneficiary’s Signature
If the Beneficiary is not the Decedent’s next of kin or legal representative, the next-of-kin or
authorized legal representative of the Decedent’s Estate must sign below:
_________________________ ___________________________
Date Authorized Person’s Signature
Description of Authorized Person’s authority to sign on behalf of Insured:
___________________________________________________________________________
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Completed 20 November 2019

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