Fill and Sign the Greater Boston Real Estate Board Purchase and Sale Agreement Form Fillable

Aggregate Stop Loss Proof of Loss Statement Mutual of Omaha Insurance Company United of Omaha Life Insurance Company Mail To: Mutual of Omaha S3-Stop Loss Claims Unit Mutual of Omaha Plaza Omaha, NE 68175 1. Employer’s Name: _______________________________________________________________________________________ 2. Stop Loss Policy Number: ____________________________________ 3. Original Effective Date: ______________________________________ 4. Policy Year of this Claim: Effective: _____________________________ Expiration: __________________________________ 5. Total Eligible Paid Claims by Employer a. Medical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ________________ b. Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ________________ c. Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ________________ d. Other (vision, disability) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ________________ e. Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ________________ 6. Minimum Annual Aggregate Attachment Point . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ________________ 7. Annual Aggregate Attachment Point . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ________________ #5 Less the Greater of #6 or #7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ________________ Less Specific Reimbursements paid or payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ________________ 8. Amount of Reimbursement due Employer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ________________ The undersigned, on behalf of the Employer, hereby affirms that all monies necessary to pay for services and supplies have been paid to the respective providers of medical services or supplies to which this claim relates. I declare, under penalty of perjury, that the foregoing is true and correct to the best of my knowledge and belief and that I am authorized to execute this Proof of Loss on behalf of the Employer. Submitted By: __________________________________________ Printed Name/Title: __________________________________ (Signature) TPA Name: _____________________________________________ Date: ______________________________________________ Address: ___________________________________________________________________________________________________ Instructions 1. Proof of loss must be completed and signed. 2. Attach a list of paid claims with an accumulated total, showing claimant’s name, incurred date of each expense, date of payment, amount of payment and check number. 3. Identify and deduct refunds, voids, and payments outside of Plan if not previously adjusted from paid claims list. 4. Calculate using greater of Minimum Annual Attachment Point or Annual Aggregate Attachment Point. Company use only Claim #: ___________________________________ Loss Date: _____________________ Loss Reserve: ____________________ Plan: ______________________________________ Max: _________________________ Expense Reserve: ________________ By: ______________________________________________________________________ Date: ___________________________ Z749