GB-7H09c Accelerated Benefits Claim Form - New York Life - new york life your benefits resources

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Accelerated Benefits Claim Form Life Insurance Company of North America
New York Life Group Insurance Company of NY
Connecticut General Life Insurance Company
MAIL COMPLETED FORM TO: New York Life Group Benefit Solutions
Pittsburgh Claim Service Center
P.O. Box 22328 Pittsburgh, PA15222-0328
Toll Free #: 1.800.238.2125 CLEAR FORM
Fax #: 877.300.6770
NEW YORK FRAUD WARNING: 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 $5000 and the
stated value of the claim for each such violation.
CAUTION: Any person who, knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or
statement of claim containing any materially false information; (2) conceals for the purpose of misleading, information concerning any material fact
thereto, commits a fraudulent insurance act. For residents of the following states, please see the last page of this form: Arizona, California,
Colorado, District of Columbia, Florida, Kansas, Kentucky, Louisiana, Maryland, Minnesota, New Jersey, Oregon, Pennsylvania, Puerto
Rico, Rhode Island, Tennessee, Texas, Virginia or Washington.
THIS FORM IS FOR ACCELERATED BENEFITS PROCEEDS ONLY, A FEATURE OF YOUR LIFE INSURANCE POLICY.
THIS CLAIM WILL BE SUBJECT TO DELAY OR RETURN IF THESE INSTRUCTIONS ARE NOT FOLLOWED.
To the Employer / Administrator: Complete the employer section of the form and deliver to the employee for submission to the
assigned Claim Office.
TO BE COMPLETED BY THE EMPLOYER/ADMINISTRATOR FOR EMPLOYEE AND DEPENDENT BENEFITS
NAME OF EMPLOYEE (Last Name) (First Name) (Middle Initial) DATE OF BIRTH SOCIAL SECURITY NO. SEX
M F
ADDRESS (Street) (City) (State) (Zip Code) TELEPHONE #
( )
INSURED'S MARITAL STATUS
SINGLE MARRIED WIDOW/WIDOWER SEPARATED DIVORCED DOMESTIC PARTNER RELATIONSHIP CIVIL UNION
POLICY NO. OCCUPATION WAS INSURANCE ISSUED ON THE BASIS OF EVIDENCE
Yes No
PLEASE CHECK THE APPROPRIATE BLOCKS REGARDING THE INSURED'S EMPLOYMENT STATUS. Hrs/wk
Exempt Management Supervisory Union Local # Salaried Full-time
Non-Exempt Non-Management Non-Supervisory Non-Union Hourly Part-time
BASIC ANNUAL EARNINGS DATE OF LAST EARNINGS CHANGE DATE OF LAST BENEFIT INCREASE FULL FACE AMOUNT OF INSURANCE
Basic: Voluntary:
DATE HIRED EFFECTIVE DATE OF INSURANCE LAST DATE WORKED PREMIUM PAID THROUGH DATE
% OF INSURED'S CONTRIBUTION TO PREMIUM INSURED'S CONTRIBUTION WERE MADE ON HAS EMPLOYEE QUALIFIED FOR PREMIUM WAIVER IF YES, AS OF WHAT DATE?
Basic: Voluntary: PRE-TAX OR POST TAX Yes No
TO BE COMPLETED IF CLAIM IS FOR DEPENDENT BENEFITS
NAME OF DEPENDENT (Last Name) (First Name) (Middle Initial) DATE OF BIRTH SOCIAL SECURITY NO. SEX
MF
RELATIONSHIP TO EMPLOYEE FULL FACE AMOUNT OF DEPENDENT INSURANCE POLICY DEPENDENT'S OCCUPATION
Basic: Voluntary:
EMPLOYER / ADMINISTRATOR'S CERTIFICATION
NAME OF EMPLOYER OCCUPATION E-MAIL ADDRESS
ADDRESS (Street) (City) (State) (Zip Code) TELEPHONE #
THIS IS TO CERTIFY THAT THE FACTS AS INDICATED ABOVE ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
SIGNATURE OF AUTHORIZED REPRESENTATIVE TITLE DATE SIGNED
? 2021, New York Life Insurance Company, New York, NY. All rights reserved. NEW YORK LIFE and the New York Life box logo are registered trademarks of
New York Life Insurance Company. Life Insurance Company of North America and New York Life Group Insurance Company of NY are subsidiaries of New
York Life Insurance Company. Connecticut General Life Insurance Company is not affiliated with New York Life Insurance Company.
Page 1 of 9 GB-7H09c Rev. 10/2022 Ptd. in U.S.A.
INSTRUCTIONS FOR FILING (COMPLETE ALL INFORMATION)
Important
Instructions for Employer:
. Please complete the sections on page 2 of this form.
.. Please provide a copy of the beneficiary designation.
If the employee has voluntary or optional benefits, please provide proof of election or enrollment.
. Please provide this form and copies of the enrollment forms and beneficiary designation to the employee for his/her completion
.
and submission to the claim office.
Instructions for Employee:
Please complete the sections on pages 3 and 4 of this form and review the NYL GBS Survivor Assurance Program Disclosure Notice
. and the Important Claim Notice.
You must indicate which benefit you are applying for and the percentage applied for. If unsure about what benefits are available in
your plan, please check your employee benefits booklet or plan or contact your human resources or benefits administrator.
.. Please provide the requested information and dates regarding your condition.
Be sure to provide the name, address, and telephone number of the Physician/s who has treated you or is familiar with your
condition. The claim office will be writing to the Physician/s to confirm that you are eligible for benefits.
.. Complete the requested information on your medical treatments within the past five years.
Please sign the claim form.
.. Please sign and date the Disclosure Authorization.
If you are unable to sign the claim form, someone else must sign for you, indicate their relationship to you, and provide written
. proof of their ability to legally sign for you.
Please forward the fully completed form with copies of your enrollment forms and beneficiary designation to New York Life Group
Benefit Solutions, Pittsburgh Claim Service Center, P.O. Box 22328, Pittsburgh, PA 15222-0328.
Page 2 of 9 GB-7H09c Rev. 10/2022 Ptd. in U.S.A.
BENEFIT INFORMATION - TO BE COMPLETED BY EMPLOYEE
BENEFIT APPLIED FOR Specified Disease/ Nursing Care/
BENEFIT PERCENT APPLIED FOR (If applicable) DATE DIAGNOSED DATE OF FIRST TREATMENT
Terminal Illness Critical Illness Custodial Care Basic: % Voluntary: %
DIAGNOSIS OR NATURE OF CONDITION
PLEASE PROVIDE THE NAME, ADDRESS AND TELEPHONE NUMBER OF TWO (2) PHYSICIANS FAMILIAR WITH THE INSURED'S CONDITION.
NAME OF PHYSICIAN NAME OF PHYSICIAN
ADDRESS ADDRESS
CITY STATE ZIP CITY STATE ZIP
TELEPHONE NUMBER FAX NUMBER TELEPHONE NUMBER FAX NUMBER
NAME OF ANY OTHER PHYSICIANS, HOSPITALS, OR CLINICS TREATING WITHIN THE PAST FIVE YEARS
(If applying for Terminal Illness, you must furnish one additional Physician Name)
NAME ADDRESS TREATMENT PERIOD
PORTABILITY/CONVERSION
HAVE YOU APPLIED FOR PORTABILITY? YES NO APPLICATION DATE:
HAVE YOU APPLIED FOR CONVERSION? YES NO APPLICATION DATE:
PLEASE PROVIDE THE NAME OF YOUR MEDICAL INSURANCE CARRIER
HAVE YOU EVER BEEN PAID A TERMINAL ILLN ESS OR SPECIFIED DISEASE BENEFIT? YES NO
ARE YOU SUBJECT TO A QUALIFIED DOMESTIC RELATIONS ORDER? YES NO
ASSIGNMENT MADE/IRREVOCABLE If, yes, assignee/irrevocable beneficiary's signature required below giving permission for release of benefits to insured
BENEFICIARY DESIGNATED? YES NO with the concurrence that such signature will release interest/rights to policy proceeds to insured.
SIGNATURE OF ASSIGNEE/IRREVOCABLE BENEFICIARY DATE
I Certify that the Foregoing Statements are True, Correct and Complete
Signature of Claimant Date
Note: The insurance carrier will report the amount of this distribution to the IRS on a Form 1099 LTC. The benefit may be TAXABLE
INCOME. Your ability to receive certain government benefits/entitlements may be affected by receipt of this benefit. The insurance
carrier recommends that you seek advice from a tax advisor and/or attorney if you have any questions about how the election of
this benefit may affect your personal situation. Please remember that the face amount of the insurance policy will be reduced by
any accelerated benefit amount paid. Premium payable will be calculated based on the full amount of the death benefit before any
reductions were made due to the accelerated benefits paid.
New York Life Group Benefit Solutions (NYL GBS) Survivor Assurance
If your insurance benefit is $5,000 or more, NYL GBS will automatically open a free, interest-bearing account in
your name. This account, called the NYL GBS Survivor Assurance, is a convenient and secure place to keep
your proceeds while you decide how to best use them. Please review the attached NYL GBS Survivor
Assurance Disclosure Notice for full details about the account.* Account balances are the liability of the
insurance company and are not insured by the Federal Deposit Insurance Corporation or any federal agency.
The insurance company reserves the right to reduce account balances for any payment made in error. If your
life insurance benefit is less than $5,000, NYL GBS will send you a check for the total benefit amount.
*Please read the NYL GBS Survivor Assurance Disclosure Notice before signing below.
I understand that if my benefit is $5,000 or more, I will receive a NYL GBS Survivor Assurance account.
I understand that I may write a draft for the total amount in my account at any time.
I understand that the account balance may be reduced for any benefit payment by the insurance company made
in error.
I acknowledge that, if I do not separately sign the NYL GBS Survivor Assurance Section of this Claim Form, I am
not participating in the NYL GBS Survivor Assurance and that I will receive a single lump sum check for the
proceeds due if my claim is approved.
Signature* Date
*Please sign as you would sign on a check, as signature may be used for draft verification.
Page 3 of 9 GB-7H09c Rev. 10/2022 Ptd. in U.S.A.


What are the unemployment benefits in New York? In New York, the amount of unemployment benefits a former employee can receive is based on how much they earn during what is referred to as a base period or an alternative base period. Unemployed weekly benefits are calculated by dividing residents’ earnings from their highest paid quarter by 26, with $425 being the maximum amount of benefits per week.

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