Fillable SERVICEMEMBERS GROUP LIFE INSURANCE TRAUMATIC INJURY PROTECTION PROGRAM (U.S. Department of Veterans Affairs)

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SERVICEMEMBERS GROUP LIFE INSURANCE TRAUMATIC INJURY PROTECTION PROGRAM (U.S. Department of Veterans Affairs)

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Application for TSGLI Benefits
Please submit your completed claim to your branch of service below.
TSGLI Branch of Service Contacts
Branch Contact Information Submit Claim by Fax Submit Claim by E-mail
Submit Claim by Postal Mail
Army
All Components
Phone: (800) 237-1336
Website: www.hrc.army.mil/TAGD/TSGLI
(502) 613-4513
usarmy.knox.hrc.mbx.tagd-tsgli-claims
@mail.mil
US Army Human Resources Command
1600 Spearhead Division Avenue,
Dept 420 PDR-C (TSGLI)
Fort Knox, KY 40122-5402
Marine Corps
All Components
Phone: (877) 216-0825 or (703) 432-9277
Website:
www.woundedwarriorregiment.org
(800) 770-9968 t-sgli@usmc.mil HQ, Marine Corps
Attn: WWR-TSGLI
1998 Hill Avenue
Quantico, VA 22134
Navy
All Components
Phone: (866) 827-5672 (option 2)
Website: www.public.navy.mil/bupers-
npc/support/casualty/Pages/TSGLI.aspx
(901) 874-2265 MILL_TSGLI@navy.mil Commander, Navy Personnel Command
Attn: PERS-13
5720 Integrity Drive
Millington, TN 38055-1300
Air Force
Active Duty
Phone: (800) 433-0048 (210) 565-6271 afpc.casualty@us.af.mil
AFPC/DPFCS
550 C Street West
Joint Base San Antonio-Randolph,
TX 78150
Air Force
Reserves
Phone: (800) 525-0102 (720) 847-3887 casualty.arpc1@us.af.mil HQ, ARPC/DPTTE
Building 390
MS68
18420 E. Silver Creek Ave.
Buckley AFB, CO 80011
Air
National
Guard
Phone: (240) 612-9173 or (240) 612-9072
usaf.jbanafw.ngb-a1.mbx.
a1ps@mail.mil
NGB/A1PS, TSGLI Program Manager
3500 Fetchet Ave.
2nd Floor
Joint Base Andrews, MD 20762-5157
Coast Guard
Phone: (703) 872-6638
Website:
www.uscg.mil/psc/psd/fs/TSGLI.asp
(703) 872-6634
ARL-PF-CGPSC-PSDFS-
COMPENSATION@uscg.mil
Commander (PSD FS)
U.S. Coast Guard
Personnel Service Center
4200 Wilson Blvd., Suite 1100,
MAIL STOP 7200
Arlington, VA 20598-7200
Public Health
Services
Phone: (301) 427-3280
(301) 427-3431 or
(301) 427-3432
compensationbranch@psc.hhs.gov PHS Compensation Branch
8455 Colesville Rd, Rm 935
Silver Spring, MD 20910
NOAA
Corps
Phone: (301) 713-3444 (301) 713-4140 Director.cpc@noaa.gov
U.S. Dept. of Commerce
NOAA/OMAO/CPC
8403 Colesville Rd, Suite 500
Silver Spring, MD 20910
*8732601*
* 8 7 3 2 6 0 1 *
GL.2005.261 Ed. 08/2015
SERVICEMEMBERS’ GROUP LIFE INSURANCE TRAUMATIC
INJURY PROTECTION PROGRAM (TSGLI)
Administered by the Office of Servicemembers’ Group Life Insurance
SGLV 8600
Office of Servicemembers'
Group Life Insurance
SGLV 8600 Page 1
WHO IS ELIGIBLE?
Effective December 1, 2005, all service members who are insured under SGLI and …
experience a traumatic event
that results in a traumatic injury
which is listed as a qualifying loss
are eligible to receive a TSGLI payment. Service members who were severely injured between October 7, 2001 and November 30, 2005 may also be eligible
for a TSGLI payment, regardless of where their injury occurred or whether they had SGLI coverage at the time of their injury. Members should contact their
branch of service for more information.
What is a Traumatic Event?
A traumatic event is the application of external force, violence, chemical, biological, or radiological weapons, accidental ingestion of a contaminated
substance, or exposure to the elements that causes damage to your body.
What is a Traumatic Injury?
A traumatic injury is the physical damage to your body that results from a traumatic event.
What is a Qualifying Loss?
A qualifying loss is a traumatic injury that is listed on the TSGLI Schedule of Losses, which lists all covered losses and payment amounts. You may view the
complete Schedule of Losses and other TSGLI information at www.insurance.va.gov/sgliSite/TSGLI.htm Your branch of service TSGLI office will determine
whether your injury is a qualifying loss for TSGLI purposes.
HOW TO FILE A TSGLI CLAIM
Filing a TSGLI claim is a three-step process in which the service member [or guardian, power of attorney or military trustee] and a medical professional
must complete and submit the appropriate parts of the TSGLI Claim Form as follows:
Step 1 Step 2 Step 3
The service member [or guardian, power of
attorney or military trustee]…
The medical professional…
The medical professional OR the service member [or
guardian, power of attorney or military trustee]…
must complete Part A (pages 3 through 7) of the
form and give it to a medical professional to
complete Part B. Note: If a guardian or power
of attorney completes Part A, they must include
copies of letters of guardianship, letters of
conservatorship, power of attorney, or durable
power of attorney (if appropriate).
must complete Part B. must forward Parts A & B, along with medical records
that document the member’s injury and resulting loss,
to the member’s branch of service TSGLI office listed
on the front cover of this form.
*8732602*
* 8 7 3 2 6 0 2 *
GENERAL INFORMATION
The Servicemembers’ Group Life Insurance Traumatic Injury Protection (TSGLI) program provides for payment to service members who are severely
injured (on or off duty) as the result of a traumatic event and suffer a loss that qualifies for payment under TSGLI. TSGLI is designed to help
traumatically injured service members and their families with financial burdens associated with recovering from a severe injury. TSGLI payments
range from $25,000 to $100,000 based on the qualifying loss suffered.
GL.2005.261 Ed. 08/2015
Instructions on completing the TSGLI Claim Form are included in each section. When completing the form, the service member, guardian, power of attorney or
military trustee must complete the service member’s Social Security number on each page of the form. If you have questions about completing the form or if
the member is deceased, please contact the branch of service TSGLI office listed on the front cover of this form.
CLAIM DECISION AND PAYMENT
Who Makes the Decision on My Claim?
Your branch of service TSGLI office will make the decision on your claim based upon the information in Parts A and B of the TSGLI Claim Form and any supporting
medical documentation you provide. They will then forward their decision to the Office of Servicemembers’ Group Life Insurance (OSGLI) for appropriate action.
COMPLETING THE FORM
SGLV 8600 Page 2
*8732603*
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GL.2005.261 Ed. 08/2015
Who Will Receive the TSGLI Payment?
Payment will be made directly to the member. If the member is incompetent, payment will be made under the appropriate letters of guardianship/
conservatorship or a power of attorney to the guardian, power of attorney or military trustee on the member’s behalf. If the member dies after qualifying for
payment, the payment will be made to the member’s current listed SGLI beneficiary(ies). The member must survive for seven days (168 hours) from the date of
the traumatic event to be eligible for TSGLI.
How the TSGLI Payment Will be Made?
If your branch of service TSGLI office approves your claim, OSGLI will make the TSGLI benefit payment. There are three payment methods used for TSGLI
benefits: Prudential’s Alliance Account®*, Electronic Funds Transfer (EFT), or check. If you do not choose a payment option, OSGLI will make the payment
through Prudential’s Alliance Account®.
1. Prudential’s Alliance Account®* —
1) The funds in an Alliance Account begin earning interest immediately and will continue to earn interest until all funds are withdrawn. Interest is
accrued daily, compounded daily and credited every month. The interest rate may change and will vary over time subject to a minimum rate that will
not change more than once every 90 days. You will be advised in advance of any change to the minimum interest rate via your quarterly Alliance
Account statement or by calling Customer Support at (877) 255-4262.
2) The interest rate credited to the Alliance Account is adjusted by Prudential at its discretion based on variable economic factors (including, but not
limited to, prevailing market rates for short term demand deposit accounts, bank money market rates and Federal Reserve Interest rates) and may
be more or less than the rate Prudential earns on the funds in the account.
3) An Alliance Account is an interest bearing draft account established in the beneficiary’s name with a draft book. The beneficiary can write drafts for
any amount up to the full amount of the proceeds. There are no monthly service fees or per draft charges and additional drafts can be ordered at no
cost, but fees apply for some special services including returned drafts, stop payment orders and copies of statements/drafts.
4) The funds in your Alliance Account are available immediately. Use the drafts to access the account anytime you wish. You can write a
draft to yourself (which you can cash or deposit at your own bank) or write a draft to another person or to any business as you need your funds.
5) Alliance Account funds are part of Prudential’s General Account and are backed by the financial strength of The Prudential Insurance Company of
America which has been in business and serving its customers for over 130 years. The Alliance Account is not a bank account or a bank product,
and therefore, is not FDIC insured.
6) Accountholders cannot make deposits into an Alliance Account. Only eligible payments from other Prudential insurance policies or contracts may
be added to the Alliance Account.
Note: A service member’s legal guardian, military trustee, or power of attorney (POA) may choose the Alliance Account payment option as long as they
submit proof of that appointment (i.e. the appropriate documentation) with the claim. The guardian, military trustee, or POA will not have their name
added to the account, but will be able to sign Alliance Account drafts on behalf of the member.
2. Electronic Funds Transfer (EFT) — Your bank account will be electronically credited with the TSGLI payment amount. Depending on your bank,
payments will be credited three to five days from the date the payment is authorized.
3. Check Payment — A check will be issued to the service member, guardian, power of attorney or military trustee on behalf of the member.
The Bank of New York Mellon is the Administrator of the Prudential Alliance Account Settlement Option, a contractual obligation of The Prudential Insurance Company of America,
located at 751 Broad Street, Newark, NJ 07102-3777. Draft clearing and processing support is provided by The Bank of New York Mellon. Alliance Account balances are not
insured by the Federal Deposit Insurance Corporation (FDIC). The Bank of New York Mellon is not a Prudential Financial company.
First Name MI Last Name
SGLV 8600 Page 3
*8732604*
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Service member
Information
Service member’s First Name MI Service member’s Last Name
Date of Birth (MM DD YYYY)
Branch of Service at time of injury
Address of Record (number and street) Telephone Number
E-mail Address
Unit (at time of injury)
City
ZIP Code
2
3
Complete this section ONLY if a guardian, power of attorney or military trustee will receive payment on behalf of the member.
Injuries that Qualify for TSGLI Payment
In order to qualify for the TSGLI benefit, you must have experienced a traumatic event that resulted in a traumatic injury
that is listed as a qualifying loss on the TSGLI Schedule of Losses.
Definitions:
Traumatic Event — A traumatic event is the application of external force, violence, chemical, biological, or radiological
weapons, accidental ingestion of a contaminated substance, or exposure to the elements that causes damage to your body.
Traumatic Injury — A traumatic injury is the physical damage to your body that resulted from a traumatic event (illness
or disease is not covered).
Qualifying Loss — A qualifying loss is a traumatic injury that is listed on the TSGLI Schedule of Losses. You may view the
complete Schedule of Losses at www.insurance.va.gov.
Mailing Address (number and street) Apartment (if any)
City
ZIP Code
Telephone Number Fax Number
Important Note:
Please include
copies of the letters
of guardianship,
conservatorship, or
Power of Attorney, etc.
with this form.
Failure to include this
documentation will
delay payment of the
claim.
The service member,
guardian, power of
attorney or military
trustee MUST fill in
member’s Social
Security number at the
top of each page.
Important Note:
Contact information
must be completed.
Incomplete information
will delay payment of
your claim.
Guardian,
Power of
Attorney or
Military Trustee
Information
Traumatic
Injury
Information
Marines
NOAA
Active Duty
National Guard
Reserves
Coast Guard
Army
Navy
PHS
Air Force
Rank/Grade
Gender
Male
Female
Married
Single
Marital Status
Widowed
PART A - Member’s Claim Information and Authorization - to be completed by the member, guardian, power of attorney or military trustee.
Divorced
GL.2005.261 Ed. 08/2015
Third Party
Authorization
First Name MI Last Name
(Optional) I authorize the following person to speak with OSGLI or the Branch of Service about my
claim (this can be a spouse, parent, friend or another person who is helping you with your claim).
Service member’s Social Security Number
Apt. (if any)
State
State
1
GL.2005.261 Ed. 08/2015
SGLV 8600 Page 4
PART A - Member’s Claim Information and Authorization (cont’d) - to be completed by the member, guardian, power of attorney or military trustee.
Injury
Information
Information About Your Loss
Is the loss you are claiming the result of any of the following:
a. an intentionally self-inflicted injury or an attempt to inflict such injury?
Yes No
b. use of an illegal or controlled substance that was not administered
or consumed on the advice of a medical doctor?
Yes No
c. the medical or surgical treatment of an illness or disease? Yes No
d. a traumatic injury sustained while committing or attempting to commit a felony? Yes No
e. a physical or mental illness or disease (not including illness or disease caused by a
wound infection, a chemical, biological, or radiological weapon, or the accidental
ingestion of a contaminated substance)?
Yes No
If you answered yes…
to any of the questions above, you are not eligible for a TSGLI payment and should not file a claim.
If you are not sure…
whether your loss is a result of one of the items above, please contact your Branch of Service TSGLI Office to find out if you are
eligible.
Tell us about your traumatic Injury
In the box below, please describe your injury and give the date, time and location where it occurred. You must also submit
medical records with this claim that document your injuries and resulting loss. (See Part B for qualifying losses.)
Traumatic Injury Information
*8732604*
* 8 7 3 2 6 0 5 *
Service member’s Social Security Number
City ZIP Code
SGLV 8600 Page 5
*8732606*
* 8 7 3 2 6 0 6 *
PART A - Member’s Claim Information and Authorization (cont’d) - to be completed by the member, guardian, power of attorney or military trustee.
Payment Option 1 - Prudential’s Alliance Account®
Complete the mailing address below (street address only, no PO boxes.)
Service member’s Mailing Address for Payment - No P.O. Boxes Apartment, Ward or Room (if any)
City ZIP Code
Payment Option 3 - Check
Important: If you are a guardian, power of attorney or military trustee you must complete the information below
when requesting a check.
Payment
Options
Please choose one
of the three payment
options by checking
the appropriate box
and filling in the
requested information.
Payment Option 1
– Prudential’s
Alliance Account
An interest-bearing
account will be
established in the
name of the member,
who can access the
money using the draft
book. A guardian,
power of attorney,
or military trustee
may sign Alliance
Account® drafts
on behalf of the
member if proof
of appointment is
submitted with
the claim.
Payment Option 2
– Electronic
Funds Transfer
This option can be
selected by member
or, if applicable, the
guardian, power of
attorney or military
trustee. Payment
will be made to the
service member’s
bank account.
Payment Option 3 –
Check
A check will be
issued to the service
member, guardian,
power of attorney or
military trustee on
behalf of the service
member.
Payment Option 2 - Electronic Funds Transfer (EFT)
To have the payment made by EFT, fill in your banking information below.
Bank Name Bank Phone Number
First Name MI Last Name
Bank Routing Number Bank Account Number
Checking
Savings
Please choose one of the three payment options below:
GL.2005.261 Ed. 08/2015
5
Financial
Counseling
VA sponsors
financial counseling
for TSGLI recipients.
To receive this counseling, check the box below.
I would like to receive financial counseling with my TSGLI benefit.
You should get financial counseling as soon as possible after receiving your insurance money and before making any major financial decisions.
For more information on this benefit, visit www.insurance.va.gov.
Mailing Address for Payment - No P.O. Boxes Apartment (if any)
State
State
4
Service member’s Social Security Number
Customer’s Name
Street Address
City, State, Zip
Check No. 1234
PAY TO THE
ORDER OF
Bank Name
Street Address
City, State, Zip
223207349
00123012201234 1234
Dollars
The bank routing
number is always
9 digits and
appears between
the symbols
Bank Routing Number Bank Account Number
Check Number (not needed)
Sample Check
The bank account
number varies in
length and may
contain dashes or
spaces. The
symbol indicates
the end of the
account number.
$
SGLV 8600 Page 6
*8732607*
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GL.2005.261 Ed. 08/2015
WARNING: Any intentional false statement in this claim or willful misrepresentation relative thereto is subject to
punishment by a fine of not more than $10,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001)
X
Signature of service member, guardian, power of attorney or military trustee Description of Authority to
act on behalf of the member
(Guardian, POA, etc.)
Description of Authority: If the guardian, power of attorney or military trustee completes this section, they must also indicate their authority to act on
behalf of the member (e.g. guardian, conservator, etc.)
Member must complete and sign the HIPAA release on page 7
Service member’s Social Security Number
PART A - Member’s Claim Information and Authorization (cont’d) - to be completed by the member, guardian, power of attorney or military trustee.
6
Signature
Date (MM DD YYYY)
Signature
The member, guardian,
power of attorney or
military trustee must
sign here.
X
Signature of service member, guardian, power of attorney or military trustee
Description of Authority to
act on behalf of the member
(Guardian, POA, etc.)
I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, medical
examiner or other health care provider that has provided treatment, payment or services pertaining to:
or on my behalf (“My Providers”) to disclose my entire medical record for me or my dependents and any other health information
concerning me to the Branch of Service and Office of Servicemembers’ Group Life Insurance (OSGLI) and its agents, employees, and
representatives. This also includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and
tobacco, but excludes psychotherapy notes. OSGLI is an administrative unit created by Prudential to administer the Servicemembers’
Group Life Insurance Program. OSGLI administers the TSGLI program on behalf of the Department of Veterans Affairs.
I authorize all non-health organizations, any insurance company, employer, or other person or institutions to provide any
information, data or records relating to credit, financial, earnings, travel, activities or employment history to OSGLI.
Unless limits* are shown below, this form pertains to all of the records listed above.
By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply
to this authorization and I instruct My Providers to release and disclose my entire medical record without restriction.
This information is to be disclosed under this Authorization so that my Branch of Service and OSGLI may: 1) administer claims
and determine or fulfill responsibility for coverage and provision of benefits, 2) administer coverage, and 3) conduct other legally
permissible activities that relate to any coverage I have applied for with OSGLI.
This authorization shall remain in force for 24 months following the date of my signature below, while the coverage is in force,
except to the extent that state law imposes a shorter duration. A copy of this authorization is as valid as the original. I understand
that I have the right to revoke this authorization in writing, at any time, by sending a written request for revocation to OSGLI at:
80 Livingston Avenue, Roseland, NJ 07068. I understand that a revocation is not effective to the extent that any of My Providers
has relied on this Authorization or to the extent that OSGLI has a legal right to contest a claim under an insurance policy or to
contest the policy itself. I understand that any information that is disclosed pursuant to this authorization may be redisclosed and
no longer covered by federal rules governing privacy and confidentiality of health information.
I understand that if I refuse to sign this authorization to release my complete medical record, OSGLI may not be able to process
my claim for benefits and may not be able to make any benefit payments. I understand that I have the right to request and receive
a copy of this authorization.
*Limits, if any:
NOTE: This release authorizes the branch of service and OSGLI to look at medical records. You may also be asked to provide these documents.
Authorization
for Release of
Information
to Branch
of Service
and Office of
Servicemembers’
Group Life
Insurance
The member,
guardian, power
of attorney, or
military trustee
must complete and
sign this section.
Failure to
complete this
section will
delay payment
of claim
This authorization
is intended to
comply with the
HIPAA Privacy Rule.
First Name MI Last Name
Member must complete and sign the HIPAA release below:
GL.2005.261 Ed. 08/2015
SGLV 8600 Page 7
*8732608*
* 8 7 3 2 6 0 8 *
Service member’s Social Security Number
PART A - Member’s Claim Information and Authorization (cont’d) - to be completed by the member, guardian, power of attorney or military trustee.
Date of Birth (
MM DD YYYY)
Date (
MM DD YYYY)
SGLV 8600 Page 8
PART B - Medical Professional’s Statement - to be completed by a medical professional who is a licensed practitioner of the healing arts acting
within the scope of his/her practice.
Patient’s First Name MI Patient’s Last Name
Inpatient
Hospitalization
Information
Please complete
this section for
ALL patients.
Instructions:
Please check the
box next to each
loss the patient has
experienced and fill
in any additional
information
requested. Omitted
information, such
as sight or hearing
measurements, will
delay payment of
the claim.
Patient’s loss MUST
meet the definition
of loss given.
If patient is deceased, please provide:
Time of Death
Cause of Death
Name and location of hospital (if more than one hospital, list all)
Definition of a hospital – A hospital that is accredited as a hospital under the Hospital Accreditation Program of the Joint Commission on
Accreditation of Healthcare Organizations. This includes Combat Support Hospitals, Air Force Theater Hospitals and Navy Hospital Ships.
Hospital does not include a nursing home. Neither does it include an institution, or part of one, which: (1) is used mainly as a place for
convalescence, rest, nursing care or for the aged; or (2) furnishes mainly homelike or Custodial Care, or training in the routines of daily living;
or (3) is for residential or domiciliary living; or (4) is mainly a school.
:
A.M.
P. M.
1
2
Patient
Information
Date transported Date of discharge from last hospital
Date of admittance to first hospital
Date of onset
Qualifying
Losses Suffered
by Patient
3
Inpatient Hospitalization
Inpatient hospitalization for at least 15 consecutive days
Loss of sight in left eye or
anatomical loss of left eye
Best corrected visual acuity
Visual Field (degrees)
Loss of sight in right eye or
anatomical loss of right eye
Loss of Sight
Visual Acuity and Field
Reason for Inpatient Hospitalization – Please give the predominant reason the patient was hospitalized.
Traumatic Brain Injury Other Traumatic Injury
Longest Period of Inpatient Hospitalization – Please give the beginning and ending dates for the longest period of consecutive days the
patient was hospitalized as an inpatient. The count of consecutive inpatient hospitalization days begins when the injured member is transported
to the hospital (if applicable), includes the day of admission, continues through subsequent transfers from one hospital to another, and includes
the day of discharge.
OR
Check here
if still
hospitalized
Inpatient hospitalization of at least 15 consecutive
days as defined above.
Loss of Sight is defined as:
Visual acuity in at least one eye of 20/200 or
less (worse) with corrective lenses OR,
Visual acuity in at least one eye of greater (better)
than 20/200 with corrective lenses and a visual
field of 20 degrees or less OR,
Anatomical loss of eye. Loss of sight must be expected
to be permanent OR must have lasted at least 120 days
Date of onset/loss
Loss of speech
Loss of Speech
Loss of Speech is defined as:
An organic loss of speech (lost the ability to express oneself,
both by voice and by whisper, through normal organs for
speech). If a member uses an artificial appliance, such as a
voice box, to simulate speech, he/she is still considered to
have suffered an organic loss of speech and is eligible for a
TSGLI benefit.
Left Eye Right Eye
GL.2005.261 Ed. 08/2015
*8732609*
* 8 7 3 2 6 0 9 *
Service member’s Social Security Number
Date of Death (MM DD YYYY)
Date of Injury (MM DD YYYY)
SGLV 8600 Page 9
3
PART B - Medical Professional’s Statement (cont’d) to be completed by a medical professional who is a licensed practitioner of the healing
arts acting within the scope of his/her practice.
Qualifying
Losses
Suffered by
Patient (cont’d)
Important:
Facial
Reconstruction:
If the patient is
undergoing facial
reconstruction, a
surgeon MUST
certify this section
by checking the box,
printing his/her name
and signing on the
appropriate line.
2nd degree or worse burns to the body including face and head
Percentage of
body affected
Percentage of
face affected
Loss of Hearing
Burns
Facial Reconstruction
2nd degree or worse burns to the face only
Loss of hearing is defined as:
Average hearing threshold sensitivity for air conduction of
at least 80 decibels. Hearing Acuity must be measured at
500 Hz, 1000 Hz and 2000 Hz to calculate the average
hearing threshold. Loss of hearing must be clinically stable
and unlikely to improve.
Burns are defined as:
2nd degree (partial thickness) or worse burns over 20% of the
body including the face and head OR 20% of the face only.
Note: Percentage may be measured using
the Rule of Nines or any other acceptable alternative.
Facial Reconstruction is defined as:
Reconstructive surgery to correct traumatic avulsions of the
face or jaw that cause discontinuity defects, specifically
surgery to correct discontinuity loss of the following:
upper or lower jaw
50% or more of the cartilaginous nose
50% or more of the upper or lower lip
30% or more of the periorbital
tissue in 50% or more of any of the following facial
subunits: forehead, temple, zygomatic, mandibular,
infraorbital or chin.
Loss of hearing in left ear
Loss of hearing in right ear
Date of onset
Hearing Acuity
Average Hearing Acuity (measured
without amplification device)
Left Ear Right Ear
dbdb
% %
Upper or lower jaw 50% of left zygomatic
50% of cartilaginous nose 50% of right zygomatic
50% of upper lip 50% of left mandibular
50% of lower lip 50% of right mandibular
30% of left periorbital 50% of left infraorbital
30% of right periorbital 50% of right infraorbital
50% of left temple 50% of chin
50% of right temple 50% of forehead
Certification of Surgeon
Name of Surgeon
Date of first surgery
X
Signature of Surgeon
GL.2005.261 Ed. 08/2015
Coma
Coma
Coma is defined as:
Coma with brain injury measured at a Glasgow Coma Score
of 8 or less that lasts for 15, 30, 60 or 90 consecutive days.
Number of days includes the date the coma began and the
date the member recovered from the coma.
Date of onset Date of recovery
OR
Check here if coma is ongoing
Glasgow score at 15 days
Glasgow score at 60 days Glasgow score at 30 days Glasgow score at 90 days
*8732610*
* 8 7 3 2 6 1 0 *
Service member’s Social Security Number
Date of Injury (MM DD YYYY)
SGLV 8600 Page 10
5
3
PART B - Medical Professional’s Statement (cont’d) to be completed by a medical professional who is a licensed practitioner of the healing
arts acting within the scope of his/her practice.
Qualifying
Losses
Suffered by
Patient (cont’d)
Amputation is: the severance or removal of a limb or genital organ or part of a limb or genital organ, including both severance due to a
traumatic injury, or surgical removal that is required for the treatment of a traumatic injury.
Amputation of Hand
Amputation of Foot
Amputation of Hand is defined as:
Amputation of hand at or above the wrist
Above the wrist means closer to the body.
Amputation of Foot is defined as:
Amputation of foot at or above the ankle OR,
Amputation of all toes (including the big toe) on the
same foot at or above the metatarsophalangeal joint.
Above the ankle and above the metatarsophalangeal joint
means closer to the body.
Amputation of right foot
Amputation of left foot
Amputation of left thumb
Amputation of right thumb
Amputation of left hand
Amputation of right hand
I certify that the patient is undergoing limb salvage surgery as defined in the
column to the right.
Salvage of left arm
Salvage of left leg
Salvage of right arm
Salvage of right leg
Date of amputation
Date of amputation
Amputation of Fingers
Amputation of Toes
Limb Salvage
Amputation of Fingers is defined as:
Amputation of four fingers on the same hand
(not including the thumb) at or above the
metacarpophalangeal joint OR,
Amputation of thumb at or above the
metacarpophalangeal joint.
Above the metacarpophalangeal joint means closer
to the body.
Amputation of Toes is defined as:
Amputation of four toes on one foot at or above the
metatarsophalangeal joint (not including the big toe)
OR,
Amputation of big toe at or above the
metatarsophalangeal joint.
Above the metatarsophalangeal joint means closer
to the body.
Limb Salvage is defined as:
A series of operations designed to avoid amputation of an
arm or a leg while at the same time maximizing the limb’s
functionality. The surgeries typically involve bone and skin
grafts, bone resection, reconstructive, and plastic surgeries
and often occur over a period of months or years.
Submit operative report for each surgery.
Amputation of 4 toes/
left foot
Amputation of big toe/
left foot
Amputation of 4 toes/
right foot
Amputation of big toe/
right foot
Amputation of 4 fingers/
right hand
Amputation of 4 fingers/
left hand
Date of amputation
Date of amputation
Date of first surgery
Important:
Limb Salvage:
If the patient is
undergoing limb
salvage, a surgeon
MUST certify this
section by printing
his/her name and
signing on the
appropriate line.
Certification of Surgeon
Name of Surgeon
Specialty
Additional Comments
Date (MM DD YYYY)
X
Signature of Surgeon
GL.2005.261 Ed. 08/2015
*87326011*
* 8 7 3 2 6 0 1 1 *
Service member’s Social Security Number
SGLV 8600 Page 11
3
Qualifying
Losses
Suffered by
Patient (cont’d)
Quadriplegia
Paraplegia
Hemiplegia
Uniplegia
Paralysis
Genitourinary System Losses
Date of onset
Paralysis is defined as:
Complete paralysis due to damage to the spinal cord or
associated nerves, or to the brain. A limb is defined as an
arm or a leg with all its parts. Paralysis must fall into one
of the four categories listed below:
Quadriplegia - paralysis of all four limbs
Paraplegia - paralysis of both lower limbs
Hemiplegia - paralysis of the upper and lower limbs on
one side of the body
Uniplegia - paralysis of one limb
GL.2005.261 Ed. 08/2015
*87326012*
* 8 7 3 2 6 0 1 2 *
Anatomical loss
of the penis
Permanent loss of
use of the penis
Anatomical loss of
one testicle
Anatomical loss of
both testicles
Permanent loss of
use of both testicles
Anatomical loss of
the vulva
Anatomical loss of
the uterus
Anatomical loss of
the vaginal canal
Permanent loss of
use of the vulva
Permanent loss of use
of the vaginal canal
Anatomical loss of the penis is defined as:
Amputation of the glans penis or any portion of the shaft of
the penis above the glans penis or damage to the glans penis
or shaft of the penis that requires reconstructive surgery.
Above the glans penis means closer to the body.
Permanent loss of use of the penis is defined as:
Damage to the glans penis or shaft of the penis that results
in complete loss of the ability to perform sexual intercourse
that is reasonably certain to continue throughout the lifetime
of the member.
The amputation of, or damage to, one testicle that requires
testicular salvage, reconstructive surgery, or both.
Anatomical loss of both testicle(s) is defined as:
The amputation of, or damage to, both testicles that requires
testicular salvage, reconstructive surgery, or both.
Permanent loss of use of both testicles is defined as:
Damage to both testicles resulting in the need for hormonal
replacement therapy that is medically required and reasonably
certain to continue throughout the lifetime of the member.
Anatomical loss of the vulva is defined as:
The complete or partial amputation of the vulva or damage
to the vulva that requires reconstructive surgery.
Anatomical loss of the uterus is defined as:
The complete or partial amputation of the uterus or damage
to the uterus that requires reconstructive surgery.
Anatomical loss of the vaginal canal is defined as:
The complete or partial amputation of the vaginal
canal or damage to the vaginal canal that requires
reconstructive surgery.
Permanent loss of use of the vulva is defined as:
Damage to the vulva that results in complete loss of the
ability to perform sexual intercourse that is reasonably
certain to continue throughout the lifetime of the member.
Permanent loss of use of the vaginal canal is defined as:
Damage to the vaginal canal that results in complete loss of
the ability to perform sexual intercourse that is reasonably
certain to continue throughout the lifetime of the member.
Date of loss or amputation
Date of loss
Date of loss or amputation
Date of loss or amputation
Date of loss
Date of loss or amputation
Date of loss or amputation
Date of loss or amputation
Date of loss
Date of loss
PART B - Medical Professional’s Statement (cont’d) to be completed by a medical professional who is a licensed practitioner of the healing
arts acting within the scope of his/her practice.
Service member’s Social Security Number
Anatomical loss of one testicle is defined as:
SGLV 8600 Page 12
GL.2005.261 Ed. 08/2015
*87326013*
* 8 7 3 2 6 0 1 3 *
3
Qualifying
Losses
Suffered by
Patient (cont’d)
Description
of Injury/
Assistance Needed
Please provide a
description of the
injury and
descriptions of the
assistance needed to
perform each ADL.
Failure to provide this
information may delay
payment of claim.
Anatomical loss of
one ovary
Anatomical loss of
both ovaries
Permanent loss of
use of both ovaries
Total and permanent loss of
urinary system function
Anatomical loss of the ovary is defined as:
The amputation of one ovary or damage to one ovary that
requires ovarian salvage, reconstructive surgery, or both.
Anatomical loss of both ovaries is defined as:
The amputation of both ovaries or damage to both ovaries that
requires ovarian salvage, reconstructive surgery, or both.
Permanent loss of use of both ovaries is defined as:
Damage to both ovaries resulting in the need for hormonal
replacement therapy that is medically required and reasonably
certain to continue throughout the lifetime of the member.
Total and permanent loss of urinary system function
is defined as:
Damage to the urethra, ureter(s), both kidneys, bladder, or
urethral sphincter muscle(s) that requires urinary diversion
and/or hemodialysis, either of which is reasonably certain to
continue throughout the lifetime of the member.
Date of loss or amputation
Date of loss or amputation
Date of loss
Date of loss
What is the predominant reason the patient is/was unable to independently perform ADL?
Inability to Independently Perform ADL is defined as:
Inability to independently perform at least two of six ADL (bathing, continence, dressing, eating, toileting and transferring). Inability must last
for at least 15 consecutive days for traumatic brain injury and at least 30 consecutive days for any other traumatic injury.
Requires Assistance is defined as:
physical assistance (hands-on),
stand-by assistance (within arm’s reach),
verbal assistance (must be instructed because of cognitive impairment),
without which the patient would be INCAPABLE of performing the task.
Inability to Independently Perform Activities of Daily Living (ADL)
Traumatic Brain Injury Other Traumatic Injury
(Please describe injury and give reason(s) it resulted in inability to perform activities of daily living.)
PART B - Medical Professional’s Statement (cont’d) to be completed by a medical professional who is a licensed practitioner of the healing
arts acting within the scope of his/her practice.
Service member’s Social Security Number
The patient is considered unable to perform an activity independently only if he or she REQUIRES assistance to perform the activity. If the
patient is able to perform the activity by using accommodating equipment, such as a cane, walker, commode, etc., the patient is considered
able to independently perform the activity without requiring assistance.
SGLV 8600 Page 13
GL.2005.261 Ed. 08/2015
*87326014*
* 8 7 3 2 6 0 1 4 *
Unable to bathe independently
Patient is UNABLE to bathe independently if…
He/she requires assistance from another person to bathe
(including sponge bath) more than one part of the body or get
in or out of the tub or shower.
Describe assistance needed:
Start date End date
OR
Check here if inability is ongoing
physical assistance (hands-on)
stand-by assistance
(within arm’s reach)
verbal assistance (must be
instructed because of
cognitive impairment)
Unable to maintain continence independently
Patient is UNABLE to maintain continence
independently if…
He/she is partially or totally unable to control bowel and
bladder function or requires assistance from another person to
manage catheter or colostomy bag.
Describe assistance needed:
Start date End date
OR
Check here if inability is ongoing
physical assistance (hands-on)
stand-by assistance
(within arm’s reach)
verbal assistance (must be
instructed because of
cognitive impairment)
Type of assistance required (check all that apply)
Type of assistance required (check all that apply)
3
Qualifying
Losses
Suffered by
Patient (cont’d)
What is the
predominant reason
the patient is/was
unable to
independently
perform ADL?
Check the
predominant reason
the patient cannot
independently
perform ADL and
describe the injury in
the box provided.
Which ADL is the
patient unable to
perform?
Check each ADL
the patient cannot
perform;
AND;
Fill in the dates
inability began and
ended or indicate
inability is ongoing.
Unable to dress independently Patient is UNABLE to dress independently if…
He/she requires assistance from another person to get and
put on clothing, socks or shoes.
Describe assistance needed:
Start date End date
OR
Check here if inability is ongoing
physical assistance (hands-on)
stand-by assistance
(within arm’s reach)
verbal assistance (must be
instructed because of
cognitive impairment)
Unable to eat independently
Patient is UNABLE to eat independently if…
He/she requires assistance from another person to:
get food from plate to mouth OR,
take liquid nourishment from a straw or cup OR,
he/she is fed intravenously or by a feeding tube
Describe assistance needed:
Start date
End date
OR
Check here if inability is ongoing
Type of assistance required (check all that apply)
Type of assistance required (check all that apply)
physical assistance (hands-on)
stand-by assistance
(within arm’s reach)
verbal assistance (must be
instructed because of
cognitive impairment)
Inability to Independently Perform Activities of Daily Living (ADL) (cont’d)
PART B - Medical Professional’s Statement (cont’d)
to be completed by a medical professional who is a licensed practitioner of the healing
arts acting within the scope of his/her practice.
Service member’s Social Security Number
SGLV 8600 Page 14
3
Require
Assistance
is defined as:
physical
assistance
(hands-on),
without which
the patient would
be INCAPABLE
of performing
the task.
Unable to toilet independently
Unable to transfer independently
Patient is UNABLE to toilet independently if…
He/she must use a bedpan or urinal to toilet OR,
he/she requires assistance from another person with any of
the following: going to and from the toilet, getting on and off
the toilet, cleaning self after toileting, getting clothing off
and on.
Describe assistance needed:
Patient is UNABLE to transfer independently if…
He/she requires assistance from another person to move into
or out of a bed or chair.
Describe assistance needed:
GL.2005.261 Ed. 08/2015
*87326015*
* 8 7 3 2 6 0 1 5 *
4
5
Other
Information
Medical
Professional’s
Comments
To your knowledge, were any of the losses indicated in Part B due to:
a. an intentionally self-inflicted injury or an attempt to inflict such injury,
b. use of an illegal or controlled substance that was not administered or consumed on the advice of a medical doctor,
c. the medical or surgical treatment of an illness or disease,
d. a physical or mental illness or disease (not including illness or disease caused by a pyogenic infection, a chemical, biological, or radiological
weapon, or the accidental ingestion of a contaminated substance).
Use this block to provide any additional information about the patient’s injuries. When a narrative description is required, please be
complete and concise.
If yes, please explain below:
PART B - Medical Professional’s Statement (cont’d) to be completed by a medical professional who is a licensed practitioner of the healing
arts acting within the scope of his/her practice.
Service member’s Social Security Number
Qualifying
Losses
Suffered by
Patient (cont’d)
Inability to Independently Perform Activities of Daily Living (ADL) (cont’d)
Start date End date
OR
Check here if inability is ongoing
physical assistance (hands-on)
stand-by assistance
(within arm’s reach)
verbal assistance (must be
instructed because of
cognitive impairment)
Type of assistance required (check all that apply)
verbal assistance
(must be
instructed
because of
cognitive
impairment),
stand-by
assistance (within
arm’s reach),
Start date End date
OR
Check here if inability is ongoing
physical assistance (hands-on)
stand-by assistance
(within arm’s reach)
verbal assistance (must be
instructed because of
cognitive impairment)
Type of assistance required (check all that apply)
27403-0113 SGLV 8600 Page 15
*87326016*
* 8 7 3 2 6 0 1 6 *
5
X
Signature
WARNING: Any intentionally false statement in this claim or willful misrepresentation relative thereto is subject to punishment
by a fine of not more than $10,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001)
This Medical Professional’s Statement is based upon my examination of the patient, and/or, a review of pertinent medical
evidence. I understand the patient and/or I may be asked to provide supporting documentation to validate eligibility under the law.
Medical
Professional’s
Signature
7
I have observed the patient’s loss.
I have not observed the patient’s loss, but I have reviewed the patient’s medical records.
GL.2005.261 Ed. 08/2015
Name of Medical Professional
Medical
Professional’s
Information
Specialty Medical Degree
First Name MI Last Name
Medical Professional’s Address (number and street) Suite
City
ZIP Code
Telephone Number Fax Number
E-mail Address
Is the patient capable of handling his/her own affairs?
Yes No
PART B - Medical Professional’s Statement (cont’d) to be completed by a medical professional who is a licensed practitioner of the healing
arts acting within the scope of his/her practice.
Service member’s Social Security Number
State
Date (
MM DD YYYY)
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SERVICEMEMBERS GROUP LIFE INSURANCE TRAUMATIC INJURY PROTECTION PROGRAM (U.S. Department of Veterans Affairs)

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Completed 3 December 2020

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