Life Claim Packet TIAA, 1794tiaa PDF Form

Life Insurance Bene ts Application Instructions Standard Insurance Company Life Bene ts Department PO Box 2800 Portland OR 97208 800. 628. 8600 Tel Please Read Carefully The application for life insurance bene ts consists of the forms included in this packet as well as the additional information noted under item 1 below. Please ll out every space on the Proof of Death form to avoid delays in our examination of your application for bene ts. If a section does not apply or information is not available please write NONE in the space so that we know you did not overlook the particular question* If an incomplete form is received it may be returned for completion* Include the following information with the Proof of Death form* Bene ciary Statement s. See attached* If there is more than one bene ciary please make a copy of the front and back of the statement. Certi ed death certi cate. All original enrollment forms and change of bene ciary cards. For AD D and Seat Belt claims attach newspaper clippings police or accident reports and any other information available regarding the accident. Please have the Bene ciary ies carefully read and complete the Bene ciary Statement which contains information about taxes and the Standard Secure Access account. Bene ciaries may receive their funds via Standard Secure Access SSA in accordance with the terms of the group policy. SSA is a convenient interest-bearing checking account in which life insurance proceeds are deposited* With SSA the Bene ciary is able to earn interest on the life insurance proceeds while taking the time to weigh important nancial decisions that often follow the death of a loved one. The Bene ciary will be mailed a checkbook once the claim is approved* In addition all SSA accountholders have access to 24-hour customer service via a voice response unit VRU and a dedicated customer service team* Please make sure all required forms are completed and returned to our of ce. Our examination of the claim will begin when all completed forms are received* Should you have questions our of ce is available to assist you. Please call 800 628-8600 or email us at lifebene ts standard. com* SI 1794 1 of 8 4/12 Proof of Death Claim Form Please type or print* Forms may be returned for unanswered questions. Name of Deceased Effective Date of Member s Insurance Social Security No* Date of Membership/Employment Date of Birth Date member was last actively at work Had employment terminated prior to death Date of Death Reason member ceased working If Dependent Claim Name of Member Last month premium was paid for member or dependent Yes No Group Policy No* Death Insurance Class see contract Illness Date Other explain Monthly or annual salary Occupation Date of last salary increase Amount of insurance claimed Salary prior to increase Basic Life Additional Life Other specify Dependents Life Usual number of hours employee worked per week Accidental Death Amount of monthly premium paid for the insured Long Term Disability Short Term Disability Waiver of Premium Member was check all that apply Full-time Part-time Commissioned Member also had the following claims with Standard Insurance Company check all that apply Name of Bene ciary Relation Union Non-Union Active Address Hourly Salaried Retired Phone If the mailing address is a PO Box we must have a street address in addition to the PO Box mailing address. Remarks In addition to this form the following items are required Original enrollment forms and any subsequent bene ciary changes. Accident reports or other information regarding the accident. Acknowledgement I hereby certify that the answers I have made to the foregoing questions are both complete and true to the best of my knowledge and belief* I acknowledge that I have read the fraud notice on page 3 of this form* Signature of Bene t Administrator Name of Employer or Association Bene t Administrator s Name Please print Street Address Phone No* City State Zip Code Payments paid via SSA will be sent directly to bene ciary payments paid via check will be sent to policyholder unless requested otherwise. 2 of 8 Claim Form Fraud Notices Some states require us to provide the following information to you CALIFORNIA RESIDENTS 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 nes and con nement in state prison* COLORADO RESIDENTS 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 nes 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 the 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 RESIDENTS 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 nes. In addition an insurer may deny insurance bene ts if false information materially related to a claim was provided by the applicant. FLORIDA RESIDENTS Any person who knowingly and with intent to injure defraud or deceive an insurance company les a statement of claim or an application containing false incomplete or misleading information is guilty of a felony of the third degree. MARYLAND AND RHODE ISLAND RESIDENTS and willfully presents false information in an application for insurance is guilty of a crime and may be subject to nes and con nement in prison* NEW JERSEY RESIDENTS civil penalties. NEW YORK RESIDENTS 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 civil penalty not to exceed ve thousand dollars and the stated value of the claim for each such violation* PENNSYLVANIA RESIDENTS and civil penalties. ALL OTHER RESIDENTS deceive an insurance company or other person les a statement containing false or misleading information criminal penalties depending upon the state. Such actions may be deemed a felony and substantial nes may be imposed* 3 of 8 Tax Information Under the Federal Income Tax law we are required to request that you as the payee provide Standard Insurance Company as payor with your correct Social Security Number or Taxpayer Identi cation Number. Please read and complete the following information in order to comply with Federal Income Tax law. Certi cation Under Penalties Of Perjury I Certify That 1. The number shown on this form is my correct Social Security/Taxpayer Identi cation Number or I am waiting for a number to be issued to me and 2. I am not subject to backup withholding because a I am exempt from backup withholding or b I have not been noti ed by the Internal Revenue Service IRS that I am subject to backup withholding as a result of a failure to report all interest or dividends or c the IRS has noti ed me that I am no longer subject to backup withholding. Certification Instructions You must cross out item 2 if you have been notified by the IRS that you are currently subject to backup withholding because of underreporting interest or dividends on your tax return* Method Of Payment 1. Payment by Check Funds under 25 000 and for policies issued in and for residents of California Florida Kentucky Louisiana Maryland and Rhode Island payment will be made in a lump sum by check to the policyholder unless requested otherwise. 2. Payment by SSA the group policy. SSA is a convenient interest-bearing checking account in which life insurance proceeds are deposited* With SSA you are able to earn interest on the life insurance proceeds while taking the time to weigh important nancial decisions that often follow the death of a loved one. If you decide to assign a portion of your bene ts to a funeral home please include a notarized assignment form supplied by the funeral home and an itemized copy of the funeral bill* A separate check for the amount of the assignment will be delivered directly to the funeral home. Relationship to Deceased Name please print Mailing Address if this is a PO Box a street address is required Work Phone No* Home Phone No* This Portion For Use By Standard Insurance Company Only Claim No* s Policy No* s Deposit Amount Division 037 Code Transmittal Date M Sub 107 F Authorized Signature Use Only 4 of 8 Bene t Payment Standard Secure Access SSA Account The SSA Account is a money market checking account. Checks drawn on the SSA Account are payable through The Northern Trust Company Chicago Illinois. Checks for 250 or more may be written against the account balance using special checks provided* There is no limit on the number of checks that can be written against the balance of the account. A check for the full balance may be written at any time. If at any time the account balance falls below 500 the account automatically will be closed at the end of that month. The nal account balance including interest credited will be provided by mail* daily and added to the account on the last day of the month. The account accrues interest based on the 13-week U*S* Treasury Bill auction rate. Principal and any interest earned are fully guaranteed by The Standard. The interest earned on the SSA Account may be taxable. A personal tax and/or legal advisor should be consulted with questions related to tax issues and a nancial advisor should be consulted for information about other investment opportunities. An SSA Account statement showing the beginning balance any withdrawals interest credited special service charges if any and the current interest rate that the account is earning is provided monthly by mail* However there may be special fees for some services. The current special fees are 25. 00 for each check returned by the bank as unpaid such as a check written for more than the account balance and 25. 00 per check for each Stop Payment order. These fees will be deducted from the account balance and will appear on the monthly statement. The fees are applicable from the date of this disclosure and may change in the future. Depositing the total proceeds in an SSA Account fully discharges The Standard s obligation under the group life insurance policy. Additional deposits cannot be made to an SSA Account. accountholders have access to 24-hour customer service via voice response unit VRU and a dedicated customer service team* The account is not insured by the Federal Deposit Insurance Corporation FDIC. The National Association of Insurance Commissioners NAIC advises that you can contact the National Organization of Life and Health Insurance Guarantee Associations at www. Nolhga*com for information about coverage and limitations for retained asset accounts by State Guaranty Associations. While accountholders may choose not to withdraw any portion of these proceeds from their account they must keep the account active. We will contact accountholders periodically to con rm that they wish to maintain their account. If we do not receive a response the account may become dormant and presumed abandoned after which the proceeds may be transferred to the accountholder s state treasurer s of ce and the accountholder will need to le a claim with the state to get the proceeds back. If there are questions please contact The Standard Life Bene ts Department PO Box 2800 Portland OR 97208-9929 or call 800. 628. 8600. 5 of 8 6 of 8 Con rmation Certi cate in accordance with the terms and conditions outlined on the back of this certi cate. Checks drawn on the Standard Secure Access account are payable through The Northern Trust Company Chicago Illinois or any successor bank appointed by The Standard. If you have any questions please call 800. 343. 2551 Or write to us at PO Box 92987 Chicago IL 60675-2987 Possession of this Con rmation Certi cate does not necessarily mean you are an accountholder. 7 of 8 Terms and Conditions Ownership Rights Special Fees You are the owner of this account. The owner alone has the right to write checks against the account balance and to exercise all the rights and privileges provided by this account or allowed by Standard Insurance Company The Standard. Basic Services on your account are provided to you at no cost. There are no monthly services fees no per check charges and no charge for additional checks. There are special fees for special services you may incur. The current 25. 00 for each check returned by the bank as unpaid such as a check written for more than your The effective date is the date the account was established* 25. 00 per check for each Stop Payment order Interest Interest is earned on your account from the effective date at a rate based on the 13-week Treasury Bill auction rate but not to exceed 5 and as shown on your monthly statement. Interest is compounded daily and is credited to your account on the last day of the month. Principal and any interest earned in the Standard Secure Access account are fully guaranteed by The Standard. Rules and Regulations of the Bank Minimum Balance Requirements Additional deposits cannot be made into this account. Payable as drafts through The Northern Trust Company Chicago IL* Your Standard Secure Access account is also subject to applicable banking laws and regulations. Deposits account automatically will be closed at the end of that month. The final account balance including interest credited will be mailed to you. Assignments No assignment of the Standard Secure Access account will be permitted* Any attempted assignment will not be binding on The Standard its third party administrator or any successor administrator. Minimum Check Amount You may write checks for 250 or more against your account balance using the special checks provided to you. There is no limit on the number of checks you can write against the balance of your account. Changes in Terms and Conditions The Standard reserves the right to terminate this program make changes to the terms and conditions and change the commercial bank being used as a clearing facility. If termination occurs or such changes are made The Standard will notify you of the changes and any and all settlement options available. All agreements made by No other person can change or waive any of the conditions of this certificate or make any agreement that will be binding upon The Standard. Statements Each month you will receive a statement of your account showing your beginning balance any withdrawals interest credited special service charges if any see is earning. Canceled checks are not returned with your account statement but are available at a modest fee see Special Fees.