LIFE INSURANCE CLAIM TO DISABILITY BENEFITS

Transcription

1 LIFE INSURANCE CLAIM TO DISABILITY BENEFITS AXA Equitable Life Insurance Company MONY Life Insurance Company of America For Assistance: Call (800) Monday Friday, 8:00 a.m. 7:00 p.m. EST Express Mail: AXA Equitable Life Insurance Company National Operations Center Ballantyne Commons Parkway Charlotte, NC Regular Mail: AXA Equitable Life Insurance Company National Operations Center P.O. Box 1047 Charlotte, NC Fax Number: (704) INSTRUCTIONS FOR DISABILITY PREMIUM WAIVER CLAIMANT This claim kit is being provided so that consideration can be given to the establishment of a claim for Disability Premium Waiver benefits. Please note the following instructions. DO NOT COMPLETE AND RETURN THESE FORMS UNTIL TOTAL DISABILITY HAS EXISTED FOR SIX MONTHS. WHILE CLAIM IS PENDING, BE SURE TO PAY ALL PREMIUMS THAT BECOME DUE. This claim kit is made up of three essential parts. Insured s Statement of Claim for Disability Premium Waiver Benefits, Occupational Description, Disclosure Authorization and State Fraud Warnings These four documents must be fully completed and signed by the Insured (or Applicant under Supplemental Protective Benefits). If the Insured is not able to do so, the Spouse, Parent, Beneficiary, Owner or the Insured s legal representative may complete it. The owner of the policy, if other than the Insured, must also sign. Attending Physician s Statement of Disability Both sides to be fully completed by the physician who has treated the Insured during disability. Medical certification of disability must be submitted for the entire period for which claim is being presented. If certification is to be submitted by more than one physician, additional form(s) should be requested. Employer s Statement A representative of the firm for which the Insured was working when disability began should complete this. (If the Insured was self-employed, the Employer s Statement is not necessary.) Be sure that all forms are completed and signed. Completed forms are to be returned in the envelope that has been provided. Note: Any other information that you can submit, such as Social Security Disability Award Letter, Worker s Compensation Allowance, a Veteran s Administration Determination of Disability, and Employer s Retirement notification, hospital or physician s reports or other correspondence that may make reference to the onset and continuance of disability, will expedite the settlement of this claim. E14601 Cat. # (4/12)

2 LIFE INSURANCE CLAIM TO DISABILITY BENEFITS AXA Equitable Life Insurance Company MONY Life Insurance Company of America For Assistance: Call (800) Monday Friday, 8:00 a.m. 7:00 p.m. EST Express Mail: AXA Equitable Life Insurance Company National Operations Center Ballantyne Commons Parkway Charlotte, NC Regular Mail: AXA Equitable Life Insurance Company National Operations Center P.O. Box 1047 Charlotte, NC Fax Number: (704) INSURED S STATEMENT OF CLAIM FOR DISABILITY BENEFITS INSURED S INFORMATION: Please print clearly or type. List all policy numbers. If a policy has been lost or misplaced, please check the box next to that policy number Policy Number Lost Policy Number Lost Policy Number Lost Policy Number Lost 1. Your Name Last First Middle Initial 2. Date of birth 3. Social Security Number / / 1a. Your address Street (If P.O. Box, show street address also) City State Zip Code 1b. Your phone number and area code 4a. Employer s Name 4b. Employer s Address ( ) (If self-employed, complete the questions on page 2.) 5. Your occupation when disability began 6. Is this claim the result of 5a. List all prior occupations. Street a work-related illness or injury? Yes No Telephone Number City State Zip Code 7. Your last day worked prior to disability Mo. Day Year 8. If ACCIDENT If ILLNESS Describe how, where and on what date it occured and what injury resulted. Give nature and details of illness, including date of onset. Have you ever had a similar injury? Yes No Have you ever had a similar illness? Yes No If Yes, give dates: If Yes, give dates: Name and address of Physician or Hospital Name and address of Physician or Hospital 9. I was unable to work from to I worked part-time from to. mo. day yr. mo. day yr. mo. day yr. mo. day yr. 10. Check one: I am presently disabled. I am not presently disabled. Disability ceased on. mo. day yr. 11. I expect to return to work on or about. mo. day yr. 12. Indicate your highest level of education completed: College Years completed High School Years completed Primary School Years completed Please specify degree(s), diploma(s), or certificate(s) and area(s) of concentration. E Cat. # (4/12)

3 13. If treated by anyone other than the physician completing the Attending Physician s Statement of Disability in the last five years, give names, addresses and dates of treatment. (If none, so state.) Name Street Address City, State, Zip Name Street Address City, State, Zip Dates 14. Please check any and all benefits that you are eligible to receive: Applied For Receiving Date Applied Effective Yes No Yes No For Date A. Social Security / / / / B. Worker s Compensation / / / / C. State Disability Insurance / / / / D. Retirement or Pension / / / / E. Short- or Long-Term Disability / / / / F. Unemployment / / / / G. Individual or Group Disability Income / / / / H. Other / / / / Describe all disability coverage in force or applied for: Dates Company or Source (Indicate policy or claim number) Type (Worker s Compensation, State Disability, Group Disability, etc.) If you have not applied for benefits, please explain why: If self-employed, please provide the following information: a. Name of Business Telephone ( ) Address City State Zip Federal Tax Identification Number b. What is the nature of your business and what duties did you perform? c. How long had you been engaged in this business? d. Have you performed any duties (supervisory or otherwise) or visited your place of business for any reason during your disability? Give details. e. How is the business being operated in your absence? f. If business was closed or sold, when? I HEREBY DECLARE THAT ALL STATEMENTS GIVEN HEREIN ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. Dated Signed Relationship, if other than Insured E Cat. # (4/12)

4 OCCUPATIONAL DESCRIPTION Occupational Title(s) Nature of employer s business Number of hours worked in a normal week Years with employer Years in occupation List the duties of your occupation(s) in order of their importance, with a detailed description of each. Duty Hours spent each week Description Duty Hours spent each week Description Duty Hours spent each week Description Duty Hours spent each week Description Additional comments on Physical Requirements: How has your disability interfered with the performance on the job? Please describe sitting, standing and walking requirements and limitations. Signed Date Relationship, if other than Insured E Cat. # (4/12)

5 DISCLOSURE AUTHORIZATION Insured s Name (Please Print) I AUTHORIZE any: physician, hospital, clinic, other medical provider or medically related facility of health care, prepaid health plans, group policyholder or benefit plan administrator, viatical or life settlement provider or broker, insurer or reinsurer, consumer reporting agency, insurance support organization, insurance agent, employer, financial institution, the Social Security Administration, the Internal Revenue Service, the Veteran s Administration, or any other organization or person having any knowledge of me or my health to give to AXA Equitable Life Insurance Company/AXA Equitable Life and Annuity Company/MONY Life Insurance Company/MONY Life Insurance Company of America or its employees and agents, or any consumer reporting agency any information as to cause, treatment, diagnoses, prognoses, consultations, examination, tests or prescriptions with respect to my physical or mental condition or information concerning me, my occupation, employment history, earnings or finances or information otherwise needed to determine policy benefits due me. This may include (but is not limited to): HIV infection, any disorder of the immune system including Acquired Immune Deficiency Syndrome (AIDS), driving records, mental illness, or use of alcohol or drugs. I AUTHORIZE AXA Equitable Life Insurance Company/AXA Equitable Life and Annuity Company/MONY Life Insurance Company/MONY Life Insurance Company of America to request a report from the Medical Information Bureau (MIB). Upon the presentation of the original or photocopy of this signed authorization I request the Social Security Administration to release to AXA Equitable Life Insurance Company/AXA Equitable Life and Annuity Company/MONY Life Insurance Company/MONY Life Insurance Company of America any and all information regarding any claim filed for benefits under any program with the Administration. I further request the release of information regarding appeals, earnings and any other information that may determine eligibility for benefits under the Social Security Act. I AGREE that the information obtained with this Authorization may be used by AXA Equitable Life Insurance Company/AXA Equitable Life and Annuity Company/MONY Life Insurance Company/MONY Life Insurance Company of America to determine policy claim benefits with respect to Insured person. A photocopy of this form is as valid as the original and I may request a copy of this Authorization. This form will be in force for the term of coverage of the policy up to 24 months from the date shown below. I understand that if I revoke or fail to sign this authorization or alter its content in any way it may affect the handling of my claim. Date: Insured s Signature (Insured or Insured s authorized representative) / / Insured s Social Security Number Relationship, if other than Insured E Cat. # (4/12)

6 State-specific fraud warnings for insuarnce claim forms ALASKA, ARKANSAS, LOUISIANA, MARYLAND, RHODE ISLAND, TEXAS, 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. ARIZONA/CALIFORNIA: For your protection, Arizona or California 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, which may include confinement in 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. DELAWARE, FLORIDA, IDAHO, INDIANA, AND OKLAHOMA: 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. DISTRICT OF COLUMBIA, MAINE, TENNESSEE, VIRGINIA AND 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 may include imprisonment, fines or a denial of insurance benefits. KENTUCKY AND PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim for insurance 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 may be subject to criminal and civil penalties. 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 AND NEW MEXICO: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. OHIO: Any person who, with intent 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. OREGON AND ALL OTHER STATES: Any person who, with intent 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 may be guilty of insurance fraud. 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 valuation. NY STATE RESIDENTS ONLY READ AND SIGN: I have read and understand the New York State fraud warning. X POLICY OWNER S SIGNATURE DATE 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 (5,000) dollars and not more than ten thousand (10,000) dollars, 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. Insured s Signature (X) Address City State Zip Telephone ( ) Social Security No. If owner is other than Insured (X) Address City State Zip Telephone ( ) Social Security No. E Cat. # (4/12)

7 ATTENDING PHYSICIAN S STATEMENT OF DISABILITY The patient is responsible for the completion of this form by his or her physician without expense to AXA Equitable. Name of patient Date of birth / / / Mo. day year 1. History A. When did symptoms first appear or accident happen? Mo. Day Yr. B. Date patient ceased work because of disability: Mo. Day Yr. C. Has patient ever had same or similar condition? Yes No If yes, state when and describe. D. Is condition due to injury or illness arising out of patient s employment? Yes No E. Was patient referred to you by another physician? Yes No If yes, state name and address. F. Name(s) and address(es) of other treating physicians: 2. A. Primary Diagnosis. B. Secondary Diagnosis (include complications) C. Objective findings (include current x-rays, MRI s, EKG s, laboratory data and clinical findings) D. Nature of treatment (including surgery and medications prescribed) 3. A. Dates of treatment: Date of first visit: Mo. Day Yr. Date of last examination: Mo. Day Yr. B. Frequency of visits: Weekly Monthly Other (specify): C. Has patient been hospital confined? Yes No If yes, give name and address of hospital and dates of confinement. 4. Extent of Disability A. Do you consider the patient to be totally disabled from his/her own occupation? Yes No If yes, give dates: from Mo. Day Yr. to Mo. Day Yr. B. Do you consider the patient to be totally disabled from any occupation? Yes No If yes, give dates: from Mo. Day Yr. to Mo. Day Yr. C. What are the patient s present limitations? IMPORTANT PLEASE COMPLETE OTHER SIDE AXA Equitable Disability Claim Center P.O. Box 1047 Charlotte, NC (Toll-Free) Mon. Fri., 8:00 a.m. 7:00 p.m. EST E Cat. # (4/12)

8 5. What is patient s HEIGHT? WEIGHT? BLOOD PRESSURE? (last visit) 6. Classification of Impairment A. Cardiac Functional Capacity (American Heart Association): Class 1 (no limitation) Class 2 (slight limitation) Class 3 (marked limitation) Class 4 (complete limitation) B. Physical:: Class 1 No limitation of functional capacity; capable of heavy work*; no restrictions (0 10%) Class 2 Medium manual activity* (15 30%) Class 3 Slight limitation of functional capacity; capable of light work (35 55%) Class 4 Moderate limitation of functional capacity; capable of clerical/administrative (sedentary*) activity (60 70%) Class 5 Severe limitation of functional capacity; incapable of minimal (sedentary*) activity (75 100%) (as defined in the Federal Dictionary of Occupational Titles) C. Mental/Nervous (if applicable): Class 1 Patient is able to function under stress and engage in interpersonal relations (no limitations) Class 2 Patient is able to function in most stress situations and engage in most interpersonal relations (slight limitations) Class 3 Patient is able to engage in only limited stress situations and engage in only limited interpersonal relations (moderate limitations) Class 4 Patient is unable to engage in stress situations or engage in interpersonal relations (marked limitations) Class 5 Patient has significant loss of psychological, physiological, personal, and social adjustment (severe limitations) Please define stress as it relates to this patient: Has this patient been declared mentally incompetent by a court of appropriate jurisdiction? Yes No Remarks: 7. Rehabilitation A. Has patient completed any rehabilitation program? Yes No If Yes, describe: B. Is patient a suitable candidate for further rehabilitation services? Yes No C. When could trial employment commence? / / Patient s Job: Full-Time Part-Time Month Day Year Any Other Work: Full-Time Part-Time D. Would vocational counseling and/or retraining be recommended? Yes No Remarks: Remarks (Please include any additional information or medical records that will help us evaluate your patient s claim.) Physician s Name Degree Telephone Number Street Address City/Town State/Province Zip Code PHYSICIAN S SIGNATURE E Cat. # (4/12)

9 EMPLOYER S STATEMENT This form is for the purpose of considering a claim for Total Disability of the Insured named below. When completed, this form should be returned to the address below. Name of Insured Social Security Number / / TO BE COMPLETED BY LAST EMPLOYER Name of Employer: Address of Employer: Street City State Zip Telephone ( ) Date Employed: Month Day Year / / Employee Worked: Full-Time Part-Time Average Number of Hours Worked Per Week: Actual Date Employee Last Worked: Reason Employee Ceased Working: Date Employment Was Terminated (if different from date last worked) Reason Terminated: Expected Date of Return to Work: / / / / Employee s Job Title: Nature of Duties (provide copy of job description if available): Can the Employee s/insured s job be modified to accommodate his/her disability? Yes No Have any Worker s Compensation, Short-Term or Long-Term Disability benefits been paid? Yes No If Yes, please provide the name and address of the carrier, along with dates covered. From to Mo. Day Yr. Mo. Day Yr. SIGNATURE (EMPLOYER OR REPRESENTATIVE) DATE AXA Equitable Disability Claim Center Cat. # (4/12) P.O. Box 1047 Charlotte, NC (Toll-Free) Mon Fri, 8:00 a.m. 7:00 p.m. EST E