Fill and Sign the Icici Prudential Life Insurance Policy Surrender Form Icici Prudential Life Insurance Policy Surrender Form

U.S. Department of Labor Authorization For Release of Medical Information (Black Lung Benefits) Reset Office of Workers' Compensation Programs Division of Coal Mine Workers' Compensation OMB No. 1240-0034 Expires: 10-31-2015 Print 1. Miner's First Name M. I. Last Name 2. Miner's SSN 3. Claimant's First Name M. I. Last Name 4. Relationship to Miner 5. Address State City Zip Phone I hereby authorize any physician, hospital, agency, or other organization, including the National Institute of Occupational Safety and Health, (NIOSH), Appalachian Laboratory for Occupational Safety and Health (ALOSH), to disclose to the Office of Workers' Compensation Programs of the U.S. Department of Labor any medical records or other Information about (my) or (the deceased miner's) medical condition for the purpose of providing evidence related to my claim for benefits under the Black Lung Benefits Act. 8. Date (Month, day, year) 7. Signature of Claimant (or person on his behalf) Identifying Information for Hospitals Admission Date(s) Birth Date Discharge Date(s) Give any necessary additional identifying data (such as building, clinic, patient number, etc.) In-patient Out-patient Miner's address at time of hospitalization Street Address City State Zip Other: CM-936 (Rev. 09-12) Privacy Act Statement The following information is provided in accordance with the Privacy Act of 1974 (5 U.S.C. 552a), as amended. (1) Collection of this information is authorized by the Black Lung Benefits Act, as amended (30 USC 901 et seq.) and by 20 CFR 725.405. (2) The information in this form will be used to authorize medical treatment providers to release information about the miner to the Department of Labor pertinent to the black lung claim. We are authorized to collect a Social Security Number (SSN) under Executive Order 9397 (November 22, 1943) to help identify individuals in agency records and keep records accurate because other people may have the same name and birth date. Disclosure of the coal miner's social security number and the completion of this form are voluntary. While you are not required to respond, your cooperation is needed to ensure that your claim is given full and proper consideration. Failure to provide the release of medical documentation may exclude relevant medical information from consideration in the black lung claim. The failure to disclose the miner's social security number will not result in the denial of any right, benefit or privilege to which you may be entitled. (3) Information may be used by other agencies, government contractors, or persons in handling matters related, directly or indirectly, in processing this form. (4) Furnishing all requested information will facilitate accurate and timely processing of the black lung claim. Public Burden Statement Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Division of Coal Mine Workers' Compensation, Room C3526, 200 Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE. Notice If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive help from DCMWC in the form of communication assistance, accommodation and modification to aid you in the claims process. For example, we will provide you with copies of documents in alternate formats, communication services such as sign language interpretation, or other kinds of adjustments or changes to account for the limitations of your disability. Please contact our office or your claims examiner to ask about this assistance. Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. CM-936 Page 2 (Rev. 09-12)