Group Benefits Personal Benefits Living Benefit Claim Claimant s Statement

Transcription

1 Group Benefits Personal Benefits Living Benefit Claim Claimant s Statement Instructions to Insured Person/Policyholder: 1. Complete and mail this form in full as appropriate. 2. Keep a copy of all forms for your records. 3. Please print clearly. 4.This form should be completed by the Insured Person/Policyholder and the Attending Physician. The Insured Person must be terminally ill with a life expectancy as stated in their policy/certificate. The Insured Person/Policyholder completes pages 1, 2, 3 and 4. The Insured Person s Attending Physician completes pages 5 and 6. The Insured Person/Policyholder is responsible for any charges incurred for completion of the Attending Physician s Statement. If you have any questions please contact our customer service area at or outside Quebec, or, or inside Quebec. The completed forms should be mailed to: If you live outside Quebec: Halifax Group Life Claims Office PO BOX 1030 STN CENTRAL Halifax NS B3J 2X5 If you live inside Quebec: Montreal Group Life Claims Office PO BOX 395 STN PLACE-D ARMES Montreal QC H2Y 3H1 Tel: (902) Tel: (514) Fax: (902) Fax: (514) Policyholder s and Insured Person s information Policy number Policyholder s name (last, first, middle initial) Certificate number Note: This section applies to the Insured Person. The Insured Person is the person who has been diagnosed with the terminal illness, and that any references to you, your, etc. are references to this Insured Person. Insured Person's name (last, first, middle initial) Insured Person is Policyholder Date of birth (dd/mmm/yyyy) Marital status Married Single Mailing address (number, street, apt.) Spouse Telephone number Fax number Amount of Living Benefit requested (up to 50% of total coverage amount) $ Do you smoke (cigarettes, cigars, pipe etc.) or use tobacco in any other forms or any smoking cessation aids? Yes No If Yes, indicate the product smoked or used and how long you have been smoking/using that product: Page 1 of 6

2 2 Illness and medical information Describe the nature and extent of your illness. On what date did symptoms first commence? (dd/mmm/yyyy) Please describe these symptoms. Name of your Attending Physician (last, first, middle initial) Date you first became his/her patient (dd/mmm/yyyy) Address of your Attending Physician (number, street, suite) Telephone number Fax number On what date did you first consult a physician in connection with your illness? (dd/mmm/yyyy) Was it your Attending Physician you first consulted in connection with your illness? Yes No If No, supply the following information: Name of physician consulted Address (number, street, suite) What treatment have you received and are currently receiving in connection with your illness? (e.g. medication, therapy, surgery, etc.) Type of treatment Institution/Attending Physician Date (dd/mmm/yyyy) Page 2 of 6

3 2 Illness and medical information (continued) Have you consulted any other doctors or specialists in connection with your illness? Yes No If Yes, supply the following information: Name of doctor/specialist Address Date of consultation (dd/mmm/yyyy) Have you previously suffered from or received treatment for a similar or related illness? Yes No If Yes, give details, including dates: Provide the name(s), address(es) and telephone number(s) of any other doctors you have consulted in the past 5 years: Name of doctor/specialist Address Reason for consultation Date (dd/mmm/yyyy) Page 3 of 6

4 3 Policyholder's and Insured Person's Certification and Authorization I certify that I, being the policyowner with the capacity to contract, am submitting this claim for Personal Benefits Living Benefit Life Insurance proceeds, in relation to Personal Benefits coverage on my life or that of my spouse, as applicable, and that any further verbal or written statement or information provided by me in the future in support of this claim, is true and complete to the best of my knowledge. I agree that both this claim and the coverage for me or my spouse, as applicable, may be denied or terminated at any time as a result of any false, incomplete, or misleading information having been provided in support of this claim. I understand that ( Manulife ) will investigate this claim and may require personal information about me or my spouse, as applicable, including information regarding our activities, income, employment, education and training, health, and medical history and treatment, including clinical notes (collectively referred to in this authorization as Information ). I authorize any person or organization who has Information pertaining to this claim, including any employer, group plan administrator, health care professional, health care institution, pharmacy and any other medically-related facility, rehabilitation provider, insurer, administrators of government benefits or other benefit programs, the Medical Information Bureau and investigative agency, to release the Information requested by Manulife, its reinsurers and/or its claims service providers for the purpose of plan administration, audit, assessment, investigation, including independent medical assessments and management of this claim for Personal Benefits Living Benefit Life Insurance proceeds (collectively, the Purposes ). Where this claim pertains to my spouse, I certify that I am authorized to consent to the collection, use, maintenance, exchange and disclosure of Information pertaining to my spouse, for the Purposes. I authorize Manulife, its reinsurers and/or claims service providers to collect, use, maintain and disclose to the persons or organizations listed above and/or each other any Information needed for the Purposes. I authorize the use of my Social Insurance Number (SIN) for the purposes of tax reporting. I authorize the use of my SIN for the purposes of identification and administration, if my SIN is used as my certificate number. I agree that a photocopy or electronic version of this authorization shall be as valid as the original. I understand that any personal information provided to or collected by Manulife in accordance with this authorization, will be kept in a Personal Benefits file. Access to your Information will be limited to: Manulife employees, representatives, reinsurers, and service providers in the performance of their jobs; Persons to whom you have granted access; and Persons authorized by law. I understand that Manulife s Privacy Policy is available at or upon request. I understand that I have the right to request access to the personal information in my file, and, where appropriate, to have any inaccurate information corrected. Policyholder s signature Insured Person s signature (if spouse is Insured Person) Page 4 of 6

5 Group Benefits Personal Benefits Living Benefit Claim Attending Physician Statement If there is a charge for completion of this section, payment is the responsibility of the claimant. Please print clearly. The completed form should be mailed to: If you live outside Quebec: Halifax Group Life Claims Office PO BOX 1030 STN CENTRAL Halifax NS B3J 2X5 Tel: (902) Fax: (902) The concept behind the Living Benefit is to advance funds from the life insurance policy prior to death for an individual diagnosed as having a life expectancy as specified under their policy/certificate of insurance. 1 Patient authorization If you live inside Quebec : Montreal Group Life Claims Office PO BOX 395 STN PLACE-D ARMES Montreal QC H2Y 3H1 Tel: (514) Fax: (514) Patient's name (last, first, middle initial) Policy number Certificate number To be completed by patient. I hereby authorize the release to of any medical information in my file including, but not limited to, copies of all consultation reports, clinical notes, test results and hospital records, for the purpose of administering the group plan and assessing my claim. I understand that I am responsible for any fees related to the completion of this form. Patient s signature 2 Attending Physician s statement To be completed by Attending Physician Primary diagnosis (If cancer, please provide details of the pathology and staging, including a copy of the pathology report if available. For other conditions, please summarize briefly the major prognostic indices. Enclose copies of any surgical or consultation reports that support the diagnosis.) Date symptoms began (dd/mmm/yyyy) Date diagnosis made (dd/mmm/yyyy) What is the current status/stage of the disease? What is the prognosis/expected life expectancy? (In your opinion is life expectancy less than 12 months?) Has the patient ever had the same or similar condition? Yes No If Yes, please state when and describe. Is the patient competent to make financial decisions? Yes No If No, from what date? (dd/mmm/yyyy) Page 5 of 6

6 2 Attending Physician s statement (continued) Treatment Nature of treatment (Provide type of treatment to date as well as planned treatments/procedures with regards to diagnosis.) What are the remaining treatment options? Have you treated or advised the patient during the last five years, prior to last illness? Yes No If Yes, provide the following details: Nature of illness Approximate date (dd/mmm/yyyy) Did the patient, to your knowledge, receive treatment during the last five years from any other physician, hospital or institution? Yes No If Yes, provide the following details: Name (physician, hospital, institution) Address Nature of illness Approximate dates (dd/mmm/yyyy) To your knowledge, does the patient smoke cigarettes or use other tobacco or nicotine products? Yes No Unknown If Yes, indicate the product that is used and how long the patient has smoked. Additional comments/information that you believe may help in the assessment of this claim. 3 Attending Physician's personal information Attending Physician s full name (last, first, middle initial) Address (number, street and suite) Speciality (if applicable) Area code and phone number Area code and fax number Attending Physician s signature I certify that the information in this form, and any further verbal or written statement provided by me in the future, is true and complete to the best of my knowledge. The information in this statement will be kept in a Personal Benefits File with and might be accessible by the claimant or third parties to whom access has been granted or those authorized by law. By providing the information I consent to such unedited release of any information contained herein. Attending Physician s signature Page 6 of 6