Fill and Sign the Nc Financial Affidavit Form

AD&D Claims Affidavit of Preference Beneficiary Ancillary Accidental Death Ancillary Eye or Limb Loss 10/15/09 Visit our Website at http://mutualofomaha.com 1 Affidavit of Preference Beneficiary Beneficiary Information If the beneficiary on record dies before the insured person, or if there was no beneficiary named, benefits are paid to the estate of the insured person unless the policy has a Preferential Beneficiary provision. If the benefits are to be paid to the estate, a certified copy of the Letters of Administration for the estate of the insured person is required. If the named beneficiary died prior to the insured person, a copy of the beneficiary's death certificate is also required. If your policy has a provision for Preferential Beneficiary, one Affidavit of Preference Beneficiary must be completed, notarized and included with the claim. Use the applicable form. You may obtain claim forms from your Group Office or visit our website. A claim form will need to be completed by the Personal Representative who is handling the estate and submitted with the Affidavit of Preference Beneficiary. If the beneficiary is a minor or is legally incompetent, it is necessary that we have a certified copy of the Appointment of Guardianship for the estate of the minor or for any legally incompetent individual's estate. The guardian of the beneficiary is responsible for consulting their legal counsel for assistance. A claim form will also need to be completed by the court-appointed Guardian. 10/15/09 Visit our Website at http://mutualofomaha.com 2 Ancillary Accidental Death Claim How to Complete The Accidental Death Form • Statement of Master Policyholder or Group Administrator These questions should each be answered as completely and accurately as possible. • The front side of this form must be completed by the beneficiary of record, as designated on the enrollment form or the latest beneficiary form. Each beneficiary must complete a separate form and the authorization at the bottom of the form. • The Statement of Attending Physician must be completed if applicable. • Please attach the policy report and toxicology records. • You may obtain claim forms from your Group Office or visit our website. Note: 10/15/09 Employers must attach the original enrollment form/records plus any beneficiary changes to the Accidental Death Benefits form. If a dependent has a claim, you must submit to us a photocopy of the employee's original Enrollment Form. Visit our Website at http://mutualofomaha.com 3 Ancillary Accidental Eye or Limb Loss How to Complete and File an Accidental Eye or Limb Loss Claim form: 1. Statement of Claimant and Authorization These questions should each be answered as completely and accurately as possible. 2. Statement of Attending Physician The physician should complete this section and return the form to you, the benefits administrator. 3. Statement of Master Policyholder or Group Administrator Upon receipt of the completed form, you must complete this section. You may obtain claim forms from your Group Office or visit our website. After you have fully completed this form, attach copies of the following materials: • Office notes for the period of treatment to the present • Test results showing objective findings • Hospital discharge summaries • Consulting physician reports 10/15/09 Visit our Website at http://mutualofomaha.com 4