Globe Life And Acciden
t Insurance Company
In
surance Services Division P.O. Box 8076 • McKinney, Texas 75070
PROOFS OF DEATH CLAIMANT’S STATEMENT
Please carefully read all of the following information before co
mpleting this statement.
Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty
of a crime and may be subject to fines and
confinement in state prison.
Arkansas, Louisiana, Rhode Island, Texas and West Virginia: 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.
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.
California: For your protection California law requires that you be made aware of the following: 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 a state prison.
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 or 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 to be informed that any person who presents a fraudulent claim for payment of a
loss or benefit is guilty of a crime punishable by fines or imprisonment, or both.
Idaho: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing
any false, incomplete or misleading information is guilty of a felony.
Indiana: Any 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.
Kentucky: Any person who knowingly or 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.
Maine: It is a crime to knowingly provide false, in
complete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
Minnesota: Any person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilt of a crime.
New Hampshire: Any person who, with a purpose to inure, 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 c
ivil penalties.
N
ew 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 insu
rance is guilty of a crime and may be subject to civil fines and criminal penalties.
Ohio: Any person who, with in
tent to defraud or knowing 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.
Ok
lahoma: WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer, makes any claim for the
proceeds of an
insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Oregon: A
ny person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
materially f
alse information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in
prison.
Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement o
f 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 civ
il
penalties.
Tennessee, Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company f
or the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Page 1 of 4
Page
2
of 4
Globe Life And Accident Insurance Company
Insurance Services Division • P.O. Box 8076 • McKinney, Texas 75070
PROOFS OF DEATH — CLAIMANT’S STATEMENT
INSTRUCTIONS
1. Claimant's Statement (Page 2) should be completed for all claims and must be executed by the beneficiary or beneficiaries named in
the policy. The 'Beneficiary's Information' (including Social Security Number) is required for each claimant.
2. If the beneficiary is a minor, or is otherwise incapacitated, the Claimant’s Statement (Page 2) must be executed by the guardian with
letters of guardianship attached.
3. If any named beneficiary in the policy died before the insured, a death certificate of such deceased beneficiary must be attached.
4. Where the claimant is the executor or administrator of the estate of the insured, such person should complete Claimant’s Statement
(Page 2), and letters testamentary or letters of administration must be attached.
Give names and addresses of the physicians or other practitioners who, to your knowledge, attended the patient during
the past five years.
Name
Address/Phone
Disease or Impairment
Beneficiary's Information
Beneficiary Name: ________________________________________________________ Relationship to Deceased: ____________________________________________
Address: ___________________________________________________________________________________________________________________________________________
Street City State Zip
Social Security Number:______________________ Date of Birth:____________________
Phone: Home______________________ Work:_____________________ Email Address:__________________________________________________________________
Signature of Beneficiary:_________________________________________________________________________ Date:___________________________________________
Additional Beneficiary:
Beneficiary Name: ________________________________________________________ Relationship to Deceased: ____________________________________________
Address: __________________________________________________________________________________________________________________________________________
Street City State Zip
Social Security Number:______________________ Date of Birth:____________________
Phone: Home______________________ Work:_____________________ Email Address:__________________________________________________________________
Signature of Beneficiary:________________________________________________________________________ Date:___________________________________________
Part B: Complete Only If Policy Is Less Than 2 Years Old
PART A:
Insured's Information
Insured/Deceased's Full Name____________________________________________________________________________________________________________________
List any other names by which the deceased may have been known such as maiden name, hyphenated name, nick name, alias, or derivative form of first and/or middle name
____________________________________________________________________________________________________________________________________________________
Policy Number(s)__________________________________________________________________________________________________________________________________
Insured/Deceased's Date of Birth____________________ Date of Death____________________ Cause of Death________________________________________
Insured/Deceased's Address at time of Death_____________________________________________________________________________________________________
Is policy less than two years old?
Yes
If "Yes", please also complete Page 3 and 4. If "No", complete Page 2 only.
Was the death ruled an accident or homicide?
Yes
If "Yes", please also include the autopsy, toxicology and police reports, a copy of coroner's
report and copies of dated newspaper articles.
No
No
Street Address City State Zip
Page 3 of 4
Part C: Complete Only If Policy Is Less Than 2 Years Old
____________________________________________________________________
Physician's Signature
___________________________________________________________________
Physician's Printed Name
(_______)__________________________________________________________
Fax Number
____________________________________________________________________________
Street Address
____________________________________________________________________________
City State Zip Code
(________)__________________________________________________________________
Phone Number
Name
Address/Phone
Disease or Impairment
Give names and addresses of the referring physicians or other practitioners who, to your knowledge, attended the patient during the past
five years.
Was the patient confined to a hospital during
the past 3 years? If so, provide name and
address of the hospital.
From what other disease or impairment has
the patient suffered, and when?
Disease or Impairment Duration
Was the patient ever treated for drug or
alcohol abuse? If so, please list dates
and locations of treatment.
When was the patient diagnosed with the
disease or impairment that resulted in death?
Were you the patient's medical attendant or
advisor before last illness or infirmity? If so,
when and for what disease?
How long have you treated the patient?
Full name of patient
Name
Age
STATEMENT OF PHYSICIAN
This statement should be completed by the Insured's Primary Care Physician Policy Number: _____________________
Was the patient ever disabled? If so, when
and for what reason?
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
Insured's Name: Date of Birth:
Social Security Number: Policy Number:
Insured's Address:
Authority to sign on behalf of patient:
Legal Guardian
Spouse
Parent
Child
Next of Kin
Executor of Estate
Other (please specify relationship to insured): ___________________________________________________________________________
Name of person signing form: _________________________________________________________________________________________________
Name and address of person(s) or category of person to whom this information will be sent:
Globe Life And Accident Insurance Company
PO Box 8076
McKinney, TX 75070
I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, pharmacy benefit manager, medical
facility, other insurance company, consumer reporting agency, Medical Information Bureau (MIB), or other health care provider that has
provided payment, treatment or services to me or on my behalf ("My Providers") to disclose my entire medical record and any other
protected health information concerning me to the below named entity and its agents, employees, and representatives. This includes
information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases. This also
includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and tobacco; but excludes psychotherapy
notes.
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 any physician, health care professional, hospital, clinic, medical facility, or other health care provider to release and
disclose my entire medical record without restriction.
This protected health information is to be disclosed under this authorization in order to: 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 or have applied for.
This authorization shall remain in force for 24 months following the date of my signature below, and 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 the entity named below at the address also listed. 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 the named entity 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 re-disclosed and no longer covered
by federal rules governing privacy and confidentiality of health information.
I understand that My Providers may not refuse to provide treatment or payment for health care services if I refuse to sign this authorization. I
further understand that if I refuse to sign this authorization to release my complete medical record, GL may not be able to process my claim
or make any benefit payments. I have received a copy of this authorization.
IMPORTANT: If the patient is deceased, please INITIAL on of the statements below:
_____I am the Administrator/Executor for the deceased and Letters of Testamentary, Executor of Estate documents, or other comparable
_____There is no court appointed Administrator/Executor and I am the Next of Kin.
I hereby certify that the information furnished by me in support of this claim is true, correct and complete to the best of my knowledge.
Signature of patient or personal representative: ___________________________________________ Date Signed: ________________________________________
Page 4 of 4
documentation is enclosed.
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