Accelerated Benefit Rider Claim Form

Accelerated Benefit Rider Claim Form

American General Life Insurance Company
A member of American International Group, Inc. (AIG)
P O BOX 305800 • Nashville, TN 37230-5800

PART A - To be completed by Owner of the policy(ies) under which the claim is being filed.

Policy Numbers

Other Policy Numbers under which a claim is being filed

Claimant/Owner’s Contact Information

Name Street

City State Zip Code Phone Number

I want to make a claim for all accelerated benefits under the policy(ies) listed above.

I want to make a claim under the Chronic Care Income Rider attached to under one or more of the policy(ies) listed above.

The actual payment received as an accelerated benefit, if any, will be less than the portion of the policy amount accelerated.

Under certain circumstances where an insured’s mortality (i.e., the Company’s expectation of the insured’s life expectancy) is not significantly changed by a Critical Illness or Chronic Illness, the accelerated benefit may be zero.

Statement Regarding Effect of Payment of Accelerated Death Benefits

In determining whether you wish to file a claim under an accelerated benefit rider attached to your life insurance policy, you should consider the effect that the payment of any accelerated death benefit would have on the policy’s cash value, accumulation account, death benefit, premium, and policy loans, as applicable. The specific effects that the payment of accelerated benefits under the terms of your policy will be provided to you at such time as we may notify you of eligibility to receive an accelerated benefit amount, if any, and send you an election form.

The receipt of accelerated death benefit payments may adversely affect your eligibility for Medicaid or other government benefits or entitlements. In addition, receipt of an accelerated death benefit payment may be taxable and assistance should be sought from your personal tax adviser.

------- Payment of Benefit -------

If your insurance benefit is $50,000 or more, you may elect to have the proceeds paid through a free, interest-bearing account called the Convenience Benefit Account®.

• This is a draft account whereby you may draw down the insurance proceeds and interest by drafting drafts which are payable through State Street Bank and Trust Company.
• A personal draft book will be mailed to you once your claim has been approved. You may access your account by writing a draft for $250.00 or more.
• There are no monthly service charges, per-draft charges or draft fees.
• Should your Convenience Benefit Account balance drop below $10,000, the account will be automatically closed and a draft for the balance mailed to you, with accrued interest on the 10th day of the following month.
• You will receive a monthly statement, showing all transactions, interest credited and the applicable rate(s) of interest for the period.
• The interest rate is subject to periodic review and may be adjusted by the company.
• Both your principal and any interest you earn are guaranteed by American General Life Insurance Company.

Select one of the following choices:

Please pay the insurance proceeds through the Convenience Benefit Account (Not available if you are a resident of Alaska, Arkansas, Connecticut, Indiana, Kansas, Kentucky, Louisiana, Maryland, New Jersey, Rhode Island and New York).

Please pay the insurance proceeds by check.

If you do not select one of the options above for payment, any proceeds payable will be paid by company check.

I hereby agree that I have reviewed any Important Claim Notice set forth in this form and applicable to me and have reviewed the Important Consumer Disclosures Regarding Accelerated Benefit Riders contained in this form.

If my claim is under an Accelerated Benefit Rider (QoL SelectChoice ABR), Critical Illness Accelerated Benefit Rider, Chronic Illness Accelerated Benefit Rider, or Terminal Illness Accelerated Benefit Rider, I acknowledge by my signature below the following:

(a) if an accelerated benefit is payable, the Company will provide the Owner with one (1) opportunity to elect such accelerated benefit under the Policy as to the same qualifying event, and

(b) the Owner must complete an election form and return it to American General Life within 60 days of receipt of the election form.

Policyowner’s Social Security Number/Tax Identification Number:

IRS Certification:

Under penalties of perjury, I certify that: (1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and (2) I am not subject to backup withholding because:

I am exempt from backup withholding (enter exempt payee code: )

I have not been notified by the IRS that I am subject to backup withholding.

The IRS has notified me that I am no longer subject to backup withholding.

(4) The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct (enter exemption from FATCA reporting code, if applicable: )

Statement of Irrevocable Beneficiary and Assignee (if any)

Each undersigned hereby releases all rights, title, interest, and claim in and to any accelerated benefit rider proceeds claimed as to the policy identified above.

PART B – To be completed by the Insured

Name Date of Birth

When did symptoms of the condition for this claim begin?

When was a doctor or licensed health care practitioner (if applicable) first consulted for this condition?

Name

Address

Phone Number

Was there a hospital confinement for this condition?

Name

Address

Phone Number

List names of all physicians/licensed health care practitioners/hospitals that provided treatment of the Insured Person within the past five years for any illness or condition:

AGREEMENT: the Insured Person agrees:

(1) That all of the above statements and answers are complete and true to the best of his or her knowledge and belief; and

(2) To cooperate with the Company in its investigation of this claim by providing assistance including, but not limited to, completing, signing, and submitting any questionnaire or authorization form needed by the Company, in its sole opinion, to conduct its investigation.

INSURED PERSON SHOULD COMPLETE THE AUTHORIZATION TO RELEASE INFORMATION FORM 2118C (ATTACHED)

PART C – To be completed by the treating Physician (or Licensed Health Care Practitioner (LHCP) for Chronic Illness claims) who diagnosed/certified the illness/condition for which you are filing this claim.

Critical Illness Diagnosis Date of Diagnosis Diagnosis Code

Diagnosis Details

For what period of time is the insured’s diagnosed illness expected to continue?

Terminal Illness:

In my professional opinion, the insured is Terminally Ill. Yes No

Date of Diagnosis Anticipated length of insured’s life expectancy from current date

Diagnosis Details

Chronic Illness (check all that apply)

In my professional opinion, the insured is Chronically Ill as of because:

Bathing Continence Dressing Toileting Eating Transferring

And has been unable to perform the checked ADLs from to

The insured has a cognitive impairment as described under the applicable policy AND requires substantial supervision to protect himself/herself from threats to health or safety.

The cause or condition requiring substantial supervision is:

In my professional opinion, the insured is not a Chronically Ill Individual because he/she does not meet either of the Chronic Illness criteria outlined above.

I am unable to determine if the insured is Chronically Ill because:

Physician’s/LHCP’s Name, address and phone number (Name)

Street City State Zip Code Phone number

Hospital Address (Name) Street

City State Zip Code Phone number

Physician’s/LHCP’s License # Physician’s/LHCP’s Signature Date

Additional Remarks:

IMPORTANT CLAIM NOTICE

In some states we are required to advise you of the following: Any person who knowingly intends to defraud or facilitates a fraud against an insurer by submitting an application or filing a false claim, or makes an incomplete or deceptive statement of material fact, may be guilty of insurance fraud.

State-specific fraud warnings: Alabama, Alaska, Arizona, Arkansas, Louisiana, Maryland, New Mexico, Rhode Island, Texas, West Virginia, California, Colorado, Delaware, Idaho, Indiana, Oklahoma, District of Columbia, Maine, Tennessee, Virginia, Washington, Florida, Kentucky, Minnesota, New Hampshire, New Jersey, New York, Ohio, Pennsylvania, and Puerto Rico.

Important Consumer Disclosures Regarding Accelerated Benefit Riders

Disclosures Applicable to Accelerated Benefit Rider, Critical Illness Accelerated Benefit Rider, Chronic Illness Accelerated Benefit Rider, Chronic Illness Accelerated Death Benefit Rider (California), and Terminal Illness Accelerated Benefit Rider.

Please review the full disclosure language provided in the PDF, including limitations, tax considerations, and election timing requirements.

HIPAA Authorization - Life Claims

Authorization to Obtain and Disclose Information

Name of Insured (Please Print) Date of Birth

I, the Insured above or the personal representative of such Insured if deceased or under a legal disability, hereby authorize all of the people and organizations listed below to give American General Life Insurance Company and its affiliates the information described in the authorization text.

Additional entity authorized to provide information:

I understand that the information obtained will be used to determine eligibility for benefits and to detect health care fraud or abuse.

I may revoke this authorization at any time by sending a written request to American General Life Insurance Company as described in the form.

This authorization will be valid for 24 months or the duration of any claim for benefits, whichever is later.

Description of Authority of Personal Representative Control Number/Policy Number