New York Life Waiver of Premium Claim Form

Address

Telephone Number

Specify nature of the disability

If sickness, when did symptoms first appear?

If injury, describe when, where and how accident occurred.

Occupation and duties at time of disability

From what date do you claim that total disability has prevented you from performing your occupation?

From what date do you claim that total disability has prevented you from performing any occupation?

If now totally disabled, when do you expect to be able to return to work?

If not now totally disabled, on what date did total disability terminate?

Have you applied for Social Security Disability benefits? Yes No

Have you applied for Veteran Administration benefits? Yes No

Have you been approved for any other disability benefits? Yes No

I have read and understand the Fraud Statement that is applicable to the state in which I reside.

Medical Information:

Please provide the names and addresses of all physicians and hospitals who treated the insured within the last ten (10) years. If necessary, use a separate sheet of paper.

I give my permission to release information to New York Life including its agents, parent or subsidiary companies and attorneys, reinsurers, insurance support groups and independent administrators who are acting on their behalf.

Insured Signature

Doctor/Hospital Name, Address, City, State, Zip Code, Telephone Number, Dates, Condition

Note to Physician: Any fee for completing this form is not chargeable to New York Life Insurance Company and should be collected from the patient.

History

When did symptoms first appear or accident happen?

Date patient ceased work because of disability?

Has patient ever had the same or similar conditions? Yes No

If yes, explain:

Is condition due to injury or sickness arising out of patient's employment? Yes No Unknown

Name and addresses of other treating physicians:

Did another practitioner refer the patient to you? Yes No

If yes, provide names and addresses:

Diagnosis

Current Medical Condition(s)

Objective finding (including X-Ray, EKG’s, Laboratory Data and any clinical finding)

Dates of Treatment

Frequency of Visits: Weekly Monthly Other

Released from Care Date

Nature of Treatment (Including surgery and medications prescribed, if any)

Progress

Has patient Recovered Improved Unchanged Retrogressed

Is patient Ambulatory House Confined Bed Confined Hospital Confined

Has patient been hospital confined? Yes No

If yes, confined dates

Name and Address of Hospital

Cardiac

Functional capacity: Class 1 (No Limitations) Class 2 (Slight Limitations) Class 3 (Marked Limitations) Class 4 (Complete Limitations)

Blood Pressure (last visit)

Mental/Nervous Impairment (if applicable)

Define "stress" as it applies to the claimant

What stress and problems in interpersonal relations has claimant had on job?

Physical Impairments

Class 1 No limits of functional capacity, capable of heavy work / No Restrictions (0-10%)

Class 2 Medium manual activity (15-30%)

Class 3 Slight limitations of functional capacity; capable of light work (35-55%)

Class 4 Moderate limitation of functional capacity; capable of clerical/administrative activity (60-70%)

Class 5 Severe limitation of functional capacity; incapable of minimal activity (75-100%)

Prognosis

Is patient now totally disabled from present job? Yes No

What duties of patient's job is he/she incapable of performing?

Can present job be modified to allow for handling with impairment? Yes No

Is the patient disabled from all other jobs? Yes No

Do you expect a fundamental or marked change in the future? Yes No

If yes, explain

If yes, when will patient recover sufficiently to perform duties of his/her job?

When will patient recover sufficiently to perform duties of any job?

Dates of Total Disability
From Through

Dates of Partial Disability
From Through

Rehabilitation

Is patient a suitable candidate for further rehabilitation services? Yes No

When could trial employment commence? Patient's Job
Full Time Part Time

Any Other Work
Full Time Part Time

Would vocational counseling and/or retraining be recommended? Yes No

I declare that the answers on this statement are complete and true to the best of my knowledge and belief. I understand that periodic updates will be required in the event of continuing claim.

Telephone Number