Group Insurance
Please send the completed form and all attachments to:
Accelerated Benefit Option Claim Form
The Prudential Insurance Company of America
Group Life Claim Division
P.O. Box 8517
Philadelphia, PA 19176
(Use for employee/member and dependent claims)
How to complete and submit an Accelerated Benefit Option Claim Form:
1.
Disclosure Statement and Tax Certification
Employees should first carefully read the Disclosure Statement below and sign and date the Acknowledgement. They should then
read the Important Tax Information and Tax Certification (page 8) and complete, sign, and date the Tax Certification.
2. ccelerated Benefit Option Claim Form
A
Both the “Employee Statement” (page 2) and the “Group Contract Holder Statement” (page 4) attached to these instructions must
be completed. Section 1 of the “Group Contract Holder Statement” must be completed if the claim is for an employee/member or
for a dependent of an employee. The “Employee Statement” should be completed and returned to the benefits administrator (Group
Contract Holder).
3. ttending Physician Certification
A
Medical evidence of terminal illness should be submitted on the Attending Physician’s Certification form. This form should be
completed by the physician and certify the nature of the employee’s or dependent’s illness. It should be mailed to Prudential with
the Accelerated Benefit Option Claim Form.
4. ail the completed forms to:
M
The Prudential Insurance Company of America
Group Life Claim Division
P.O. Box 8517
Philadelphia, PA 19176
If you have any questions, please call our Group Life Claim Division at 800-524-0542 and a customer service representative will
assist you.
Disclosure Statement
The money received from the Accelerated Benefit Option can be used for any purpose. If you exercise this option and accept payment,
you should be aware that such payment may adversely affect your eligibility for Medicaid or other government benefits or entitlements.
In addition, the Accelerated Benefit Option payment, or a portion thereof, may be considered taxable income. Prudential recommends
that assistance be sought from a personal tax advisor and/or an attorney regarding how election of this option may affect your
personal situation. Prudential offers this option based on our interpretation of current law, which may change over time.
By electing this option, the total amount of employee or dependents term life insurance otherwise payable at death, including any
amount under an extended death benefit, will be reduced by the amount paid under the Accelerated Benefit Option and any required
contribution for that insurance will be reduced accordingly. Also, any amount that could otherwise have been converted to an
individual contract will be reduced by the amount paid under this option.
Acknowledgement: I have read the disclosure information above.
Date (mm dd yyyy)
X
Employee’s Signature
Date (mm dd yyyy)
X
Beneficiary’s Signature (Required only if irrevocable)
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Page 1 of 9
Group Insurance
Please send the completed form and all attachments to:
Accelerated Benefit Option Claim Form
The Prudential Insurance Company of America
Group Life Claim Division
P.O. Box 8517
Philadelphia, PA 19176
(Use for employee/member and dependent claims)
Employee Statement Please complete in full.
Name
Date of Birth (mm dd yyyy)
Social Security Number
Home Address
Mailing Address (if different)
Last day worked prior to current disability (mm dd yyyy)
Date first treated by physician (mm dd yyyy)
Amount being claimed
$
*If claim is for a dependent, please provide the following information:
Name
Social Security Number
List physicians consulted because of this disability
Period Treated
Name
From (mm dd yyyy)
Date of Birth (mm dd yyyy)
To (mm dd yyyy)
Dr.
Address
Dr.
Address
List any hospital confinements for this disability
Period Confined
Name of hospital
From (mm dd yyyy)
To (mm dd yyyy)
If you have any other Prudential policies, please show policy
number(s) (complete as it pertains to employee or dependent):
Has this insurance been assigned?
Yes
No
Has any government agency required that you involuntarily
exercise this option as a condition for obtaining or
r
etaining a government benefit or entitlement?
Has any creditor required that you
exercise this option?
Yes
No
Optional Payment Election
For cases sitused in Connecticut and Vermont:
Distribution will be lump sum payment only.
I hereby certify that these statements are true:
LUMP
SUM
Yes
No
TWELVE MONTHLY
INSTALLMENTS
Date (mm dd yyyy)
X
Employee’s Signature
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Claimant’s Social Security Number
Authorization for Release of Information to Prudential Insurance Company
This Authorization is intended to comply with the HIPAA Privacy Rule.
Name of Insured:
First Name
MI
Date of Birth (mm dd yyyy)
Last Name
I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, or other health care
provider that has provided treatment, payment or services pertaining to:
First Name
MI
Print Name of Deceased or Patient
Last Name
or on my (his/her) behalf (“My Providers”) to disclose my (his/her) entire medical record for me or my dependents and any other health
information concerning me (him/her) to The Prudential Insurance Company of America (Prudential) and its agents, employees, and
representatives. This includes information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually
transmitted diseases. This also includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and
tobacco, but excludes psychotherapy notes.
I authorize all non-health organizations, any insurance company, employer, or other person or institutions to provide any information, data
or records relating to credit, financial, earnings, travel, activities or employment history to Prudential.
Unless limits* are shown below, this form pertains to all of the records listed above.
By my signature below, I acknowledge that any agreements I (he/she) have made to restrict my (his/her) protected health information do
not apply to this authorization and I instruct My Providers to release and disclose my (his/her) entire medical record without restriction.
This information is to be disclosed under this Authorization so that Prudential may: 1) administer claims and determine or fulfill
responsibility for coverage and provision of benefits, 2) obtain reinsurance; 3) administer coverage; and 4) conduct other legally
permissible activities that relate to any coverage I (he/she) have (has) or have (has) applied for with Prudential.
This authorization shall remain in force for 24 months following the date of my signature below, while the coverage is in force, except
to the extent that state law imposes a shorter duration. A copy of this authorization is as valid as the original. I understand that I have
the right to revoke this authorization in writing, at any time, by sending a written request for revocation to Prudential at: PO Box 8517,
Philadelphia, PA 19176. I understand that a revocation is not effective to the extent that any of My Providers has relied on this
Authorization or to the extent that Prudential has a legal right to contest a claim under an insurance policy or to contest the policy itself.
I understand that any information that is disclosed pursuant to this authorization may be redisclosed and no longer covered by federal
rules governing privacy and confidentiality of health information.
I understand that if I refuse to sign this authorization to release my complete medical record, Prudential may not be able to process my
claim for benefits and may not be able to make any benefit payments. I understand that I have the right to request and receive a copy of
this authorization.
*Limits, if any:
Date (mm dd yyyy)
X
Signature of Insured/Patient or Personal Representative
Description of Personal Representative’s
Authority or Relationship to Patient
NOTICE TO MONTANA RESIDENTS: You or your authorized representative are entitled to receive a copy of this Authorization, and
upon request, a record of any subsequent disclosures of personal or privileged information.
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Group Insurance
Please send the completed form and all attachments to:
The Prudential Insurance Company of America
Group Life Claim Division
P.O. Box 8517
Philadelphia, PA 19176
Accelerated Benefit Option Claim Form
(Use for employee/member and dependent claims)
Group Insurance Contract Holder Statement To be completed by Employer/Plan Administrator. Please complete all five sections.
1
Claimant’s
Information
First Name
MI
Date of Birth (mm dd yyyy)
Social Security Number
Female
Employee
Spouse
Child
AKA: First Name
2
Employee/
Member
Information
Date of Disability (mm dd yyyy)
Relationship to Employee
Gender
Male
Last Name
State of
Residence
Other
Last Name
First Name
MI
Social Security Number
Date of Employment (mm dd yyyy)
Last Name
Date of Birth (mm dd yyyy)
Hourly
Union
Salary
Non–union
Date Last Worked (mm dd yyyy)
Part Time
Full Time
Occupation
Where Employed
If not actively at work immediately prior to disability, what was the reason? (Attach explanation, if applicable.)
Disability
Leave of Absence
Vacation
Discharge
Resigned
Retired
Temporary Layoff
Other
Street Address (where employed)
City
State
3
Employer/
Association
Information
Employer’s Name
Street Suite
City
State
Telephone Number
GL.2002.140 (12)
ZIP Code
ZIP Code
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Claimant’s Social Security Number
4
Insurance
Coverages
Complete only the coverage(s) that apply to this claim.
Group Coverage
Control Number
Amount
Basic Term Life
Effective Date of Coverage (mm dd yyyy) Branch
$
.
.
.
.
.
Dependent Group
Universal Life
Dependent
Group Variable
Universal Life
Group
Variable
Universal Life
.
Group Universal Life
Dependent
Life Optional
Term
Dependent Term Life
.
Optional Term Life
.
Employee/Member Salary Amount on Last Day Worked
$
Was insurance
ever assigned?
.
per
Yes
Hour
Week
Month
No
Year
Optional Term Life, if applicable, must be supported by proof of enrollment.
Maximum Amount Available Under the Accelerated Benefit Option
$
.
Please enter amount being claimed under each applicable coverage
Group Coverage
Amount to be Distributed
$
$
Was evidence of
insurability required to
secure current coverage?
GL.2002.140 (12)
Yes
No
.
If yes, provide date (mm dd yyyy):
No
Yes
.
$
Has insurance percentage
increased in last two years?
.
Is there
contributory
insurance?
Yes
No
Date Last Premium Paid (mm dd yyyy)
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Claimant’s Social Security Number
5
Payment
Information
Mail payment to:
mployer at address
E
laimant at address
C
listed on previous page
ther (please specify in
O
listed below
cover letter)
Please provide the following information about the claimant.
Name of Claimant
Date of Birth (mm dd yyyy)
Social Security Number
Telephone Number
Relationship to Employee
Residence: Street
Apt.
City
State
ZIP Code
Completed by (name of representative of the employer or benefit administrator)
Please print
or type name
Date (mm dd yyyy)
Signature
GL.2002.140 (12)
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Group Insurance
Accelerated Benefit Option Claim Form Attending Physician’s Certification (Please print)
The patient is responsible for the completion of this form without expense to Prudential.
Name of Patient
Date of Birth (mm dd yyyy)
Social Security Number
Patient’s Address
Employer’s Name
Control Number
Date (mm dd yyyy)
X
Patient’s Signature
I hereby authorize release of information requested on this form by the below named physician for the purpose of claim processing.
Date of first visit (mm dd yyyy)
Date of last visit (mm dd yyyy)
Diagnosis
Date total disability began (mm dd yyyy)
ICD-9-CM Disease Code
Objective Findings/include any results of current x-rays, E.K.G., or any other special test
Present Condition
Does the patient have the mental capacity
to handle his/her financial affairs?
Yes
No
If no, briefly explain:
List any hospital confinements for this disability
Period Confined
Name of hospital
From (mm dd yyyy)
To (mm dd yyyy)
To qualify for this benefit, your patient must have a life expectancy of twelve (12) months or less.
Does your patient meet
this requirement?
Yes
No
If “Yes,” briefly explain the basis for your opinion of the patient’s life expectancy. The patient’s most recent clinical records
must be provided.
Stage of Cancer
(if applicable)
Metastasis?
Yes
Name of Attending Physician (Please print)
No
If yes,
where?
Degree/Specialty
Hospice?
Yes
No
Telephone Number
Physician’s Address
X
Date (mm dd yyyy)
Signature
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Group Insurance
Please send the completed form and all attachments to:
The Prudential Insurance Company of America
Group Life Claim Division
P.O. Box 8517
Philadelphia, PA 19176
IMPORTANT TAX INFORMATION
This information will help you complete the Tax Certification section below, which is required by the Internal Revenue Service. Please
read it carefully. Prudential and its representatives cannot give legal or tax advice. You may wish to consult your tax or legal advisor
for more information.
Citizenship. You must indicate if you are not a U.S. citizen or resident alien. In that case, you must state the country of which you are
a citizen and submit a completed IRS Form W-8BEN.
Backup withholding. You must tell us if the IRS has notified you that you are subject to backup withholding because you did not
report all your taxable interest and dividends on your tax return. You are not subject to backup withholding if either (a) you
did not receive such a notice from the IRS, (b) the IRS recently told you that you are no longer subject to a backup
w
ithholding order, or (c) you are exempt from such withholding.
Taxpayer Identification Number and date of birth. You must include your Taxpayer Identification Number (TIN) and date of birth.
The TIN for the certificate is:
• our Social Security Number if you are an individual or the owner of a sole proprietorship.
Y
• he Employer Identification Number (EIN) if you represent a trust, estate, corporation, partnership, or tax-exempt organization.
T
• he TIN of the grantor/trustee or that of the actual owner of a trust-like entity not recognized as a legal or valid trust under state law.
T
Tax Certification
(See Important Tax Information above for additional information on this section)
If this section is not completed, we may be required to withhold federal and state income tax.
Complete section (a) or (b) below:
(a) nder penalities of perjury, I certify that my correct Taxpayer Identification Number is:
U
Claimant/Assignee’s Social Security Number or Employer Identification Number
Claimant’s Date of Birth
Complete the following, if applicable.
I am not subject to backup withholding for the reasons stated under “Backup Withholding” in the Important Tax
Information section. (Check the box only if you are subject to backup withholding)
have been notified by the Internal Revenue Service that I am subject to backup withholding due to
I
underreporting of interest or dividends.
(b)
I am not a U.S. person (including resident alien). I am a citizen of
(Attach completed IRS Form W-8BEN, if applicable)
The Internal Revenue Service does not require your consent to any provision of this document other than the
c
ertifications required to avoid backup withholding.
Date (mm dd yyyy)
X
Claimant’s Signature
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Group Insurance
Please send the completed form and all attachments to:
The Prudential Insurance Company of America
Group Life Claim Division
P.O. Box 8517
Philadelphia, PA 19176
For residents of all states except California, District of Columbia, Florida, Kentucky, New Jersey, New York, Pennsylvania,
Rhode Island, Utah, Vermont, Virginia and Washington; WARNING: Any person who knowingly and with intent to injure, defraud,
or deceive any insurance company or other person, or knowing that he is facilitating commission of a fraud, submits incomplete, false,
fraudulent, deceptive or misleading facts or information when filing an insurance application or a statement of claim for payment of a
loss or benefit commits a fraudulent insurance act, is/may be guilty of a crime and may be prosecuted and punished under state law.
Penalties may include fines, civil damages and criminal penalties, including confinement in prison. In addition, an insurer may deny insurance
benefits if false information materially related to a claim was provided by the applicant or if the applicant conceals, for the purpose of
misleading, information concerning any fact material thereto.
CALIFORNIA RESIDENTS — For your protection, California law requires the following to appear on this form. Any person who
knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement
in state prison.
DISTRICT OF COLUMBIA and RHODE ISLAND RESIDENTS — Any person who knowingly presents a false or fraudulent claim
for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may
be subject to fines and confinement in prison.
FLORIDA RESIDENTS — Any person knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim
or an application containing false, incomplete, or misleading information is guilty of a felony of the third degree.
KENTUCKY RESIDENTS — Any person who knowingly and with intent to defraud any insurance company or other person files
a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning
any fact material thereto commits a fraudulent insurance act, which is a crime.
NEW JERSEY RESIDENTS — Any person who knowingly files a statement of claim containing any false or misleading information
is subject to criminal and civil penalties.
NEW YORK RESIDENTS — Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a
civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
PENNSYLVANIA and UTAH RESIDENTS — Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose
of misleading, information concerning any material fact thereto commits a fraudulent insurance act, which is a crime and subjects
such person to criminal and civil penalties.
VERMONT RESIDENTS — Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes
a false statement in an application for insurance may be guilty of a criminal offense under state law.
VIRGINIA RESIDENTS — Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other
person, or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or
information when filing a statement of claim for payment of a loss or benefit may have violated state law, is guilty of a crime and may
be prosecuted and punished under state law. Penalties may include fines, civil damages and criminal penalties, including confinement
in prison. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the
applicant or if the applicant conceals, for the purpose of misleading, information concerning any fact material thereto.
WASHINGTON RESIDENTS — Any person who knowingly provides false, incomplete, or misleading information to an insurance
company for the purpose of defrauding the company commits a crime. Penalties include imprisonment, fines, and denial of
insurance benefits.
Prudential, the Prudential logo, and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many
jurisdictions worldwide.
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