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Clico medical claim form MAIL TO: COMBINED LIFE INSURANCE COMPANY OF NEW YORK Administrative Concepts, Inc. 994 Old Eagle School Road Suite 1005 Wayne, PA 19087-1802 www.visit-aci.com BOTH SIDES OF CLAIM FORM MUST BE COMPLETED

Health insurance claim form 15... Revised Health Insurance Claim Form CMS-1500 (GEN) Posted April 5, 2006 The Form CMS-1500 (12-90) is being revised to accommodate the reporting of the National Provider Identifier (NPI). The work

Hcfa 2360 fill in form Currently in production on IEC for both DDE and Batch Processing 270 Transaction Recipient Eligibility Inquiry Request 276/277 transaction The following hardcopy claim format will be accepted in the MEDI IEC System effective March 21 2005 DPA 2360 Health Insurance Claim Form DPA 1443 Provider Invoice Claim Form DPA 2209 Transportation DPA 2210 Medical Equipment/Supplies Invoice DPA 215 Drug Invoice UB92 all claims currently submitted on th...

Met life dental claim form 200... Dental Expense Claim 1. Patient First Name Middle Last 2. Relationship to Employee 3. Sex Metropolitan Life Insurance Company 4. Married? 5. Patient Date of Birth 6. For Office Use Mo. / Day / Year

Aig life insurance life clains... Fidelity Life Association, A Legal Reserve Life Insurance Company/'The Company' Administrative Office: 1211 West 22nd Street, Suite 209 Oak Brook, IL 60523 (800) 369-3990 Claim Form - Life

New york life form for waiver... The Company you Keep New York Life Insurance Company Group Membership Association C laims 5505 West Cypress Street Tampa FL 33607 (800) 792 -9686 Dear Claimant: We are sorry to learn of your unfortunate

Tsgli claim form Must forward Parts A B to the member s branch of service TSGLI office listed on the front cover of this form. Page 1 COMPLETING THE FORM Instructions on completing the TSGLI Claim Form are included in each section. When completing the form the service member guardian power completing the form or if the member is deceased please contact the branch of service TSGLI office listed on the front cover of this form. Claim decision and payment Who Makes the Decision on My Claim Your branch of service TSGLI office will make the decision on your claim based upon the information in Parts A and B of the TSGLI Claim Form. They will then forward their decision to the Office of Servicemembers Group Life Insurance OSGLI for appropriate action. Who Will Receive the TSGLI Payment Payment will be made directly to the member. HOW TO FILE A TSGLI CLAIM Filing a TSGLI claim is a three-step process in which the service member or guardian power of attorney or military trustee and a medical professional must complete and submit the appropriate parts of the TSGLI Claim Form as follows Step 1 Step 2 Step 3 attorney or military trustee The medical professional guardian power of attorney or military trustee must complete Part A pages 3 through 6 of the form and give it to a medical professional to complete Part B. SERVICEMEMBERS GROUP LIFE INSURANCE TRAUMATIC INJURY PROTECTION PROGRAM TSGLI Administered by the Office of Servicemembers Group Life Insurance Application for TSGLI Benefits Please submit your completed claim to your branch of service below. TSGLI Branch of Service Contacts Branch Contact Information Submit Claim by Fax Army All Components Phone 800 237-1336 Website www. tsgli. army. mil 866 275-0684 tsgli conus. army. mil Army Human Resources Command Traumatic SGLI TSGLI 200 Stovall Street Alexandria VA 22332-0470 Marine Corps Phone 877 216-0825 or 703 432-9277 Website https //www. manpower. usmc* mil/pls/ portal/url/page/mrahome/wwr/ wwracommandelement/wwrdregimentalstaff/3s3/wwrtsgli 888 858-2315 t-sgli usmc*mil Attn WWR-TSGLI 3280 Russell Road Quantico VA 22134 Navy Phone 800 368-3202 / 901-874-2501 DSN 882 Website www. npc*navy. mil/Command Support/ CasualtyAssistance/TSGLI 901 874-2265 MILLTSGLI navy. mil Navy Personnel Command Attn PERS-62 5720 Integrity Drive Millington TN 38055-6200 Air Force Active Duty Phone 800 433-0048 Website ask. afpc*randolph. af*mil 210 565-2348 afpc*casualty randolph. af*mil AFPC/DPWC 550 C Street West Suite 14 Randolph AFB TX 78150-4716 Reserves Phone 800 525-0102 303 676-6255 arpc*dippedl arpc*denver. af*mil HQ ARPC/DPPE 6760 E Irvington Place 4000 Denver CO 80280-4000 Air National Guard Phone 703 607-0901 703 607-0033 tsgliclaims ngb. ang. af*mil NCOIC Customer Operations Air National Guard Bureau 1411 Jefferson Davis Hwy Suite 10718 Arlington VA 22202 Coast Guard Phone 202 475-5391 202 475-5927 compensation comdt. uscg. mil COMDT CG-1222 2100 2nd Street SW Washington DC 20593-0001 Public Health Services Phone 301 594-2963 301 594-2973 or 800 733-1303 compensationbranch psc*hhs.

Sglv 8283 form Check one WARNING mprisonment SGLV-8283 El One Sum CERTIFICATION made In thus claim are true to the best of my knowledge informatron and belief and that no evidence necessary In the event the Insured has not previously elected monthly Installments. CLAIM RETURN COMPLETED FORM TO OFFICE OF SERVICEMEMBERS GROUP LIFE INSURANCE INSURANCE 80 Livingston Avenue Roseland NJ 07068-1733 Newark New Jersey 07102-2999 FOR DEATH BENEFITS Servicemen s Group Life Insurance Servicemembers Group Life Insurance Veterans lOTE* THIS FORM IS NOT TO BE USED FOR NATIONAL SERVICE JNITED STATES GOVERNMENT USGLI Policy Numbers Prefixed NAME OF DECEASED LEASE READ THE IMPORTANT Comolete Items Policy Numbers INFORMATION AND INSTRUCTIONS 11A throuah ON REVERSE I- BEFORE 14C if vou are the widow CONCERNING or widower YES VOTE - ON0 Yes. complete If vou are not the named and 14c beneficiarv* widow PART CLAIMANT -1st below the name a Wrdow If none relationship ever is no survivrng wrdow are no children Is father d If there within of deceased 15A NEXT-OF-KIN appropriate No brothers lrst the survivrng the degrees check parent Is mother Indicated marriage or children* of chrldren If yes did list all the children child in a through terminate Include NAME OF EXECUTOR ADDRESS 1 158. THEDECEASED OR d orce decree II and III. cl Death Give Date by Divorce or illegitimate stating whrch class it or parents. c. list below the next of km who may be capable of inheriting from the deceased sisfers sisters etc*. Parts any adopted here AGE 15C. RELATIONSHIP VOTE - Complete Items 16 and 77 ONLY if any of the persons listed above 5 NAME AND ADDRESS OF GUARDIAN FOR ANY MINOR CHILDREN LISTED ABOVE IF ONE HAS COURT Attach copy or appOmme f paper issued by court Of Ihe p/aces below Check of are no survivors descendants address married list the descendants None was Insured IS and age copy DIVORCE II - 3. DATE OF DEATH DEATH JS or COMPLETING attach by V H RH RS W J JR and 2 SOCIAL SECURITY NUMBER FKS mrddle. /ast NSLI by K ADMINISTRATOR Ill IF ANY. 15D. ADDRESS are under age 21. BEEN APPOINTED BY THE THE BY THE COURT TO ESTATE SETTLE OF 19 IF AN EXECUTOR APPOINTED. WILL ONE HAS NOT 0 YES q N0 HEREBY CERTIFY that all statements f this clarm is suppressed or wrthheld. I request that the death benefit be paid III 36 Eaual Monthlv Any rntentronal false statement in thus claim or willful of not more than 5 years or both. 16 U*S*C. 1001. JULY 19 SEPTEMBER 2007 IV - misrepresentation EXISTING IF ADDITIONAL SPACE to a settlement In STOCKS relative IS REQUIRED thereto is subject to punrshment by a fine of not more JAN 1991 WILL BE USED. ATTACH SEPARATE SIGNED SHEETS* than 10 000 or BEEN THIS FORM SHOULD BE USED WHEN THE DECEASED HAD INSURANCE IN FORCE UNDER SERVICEMEN S GROUP LIFE INSURANCE INSURANCE VETERANS GROUP LIFE INSURANCE VGLI. SGLI OR VETERANS GROUP LIFE INSURANCE VGLI. PAYMENT BENEFITS Under Servicemen s l To the beneficiary the widow named child or children payable to a duly appointed Group in writing Life Insurance by the insured death benefit if none the insurance if none it is payable must be made in the following is payable order to in equal shares with the share of any deceased payments child distributed among of that child if none it is other next of kin* executor or administrator FOR DEATH of the insured s estate and if none to It is important that all requested information be furnished* Omission information should be typed or printed in ink except the signature.

Claim reimbursement form 1. DEPARTMENT OR ESTABLISHMENT, BUREAU, DIVISION OR OFFICE CLAIM FOR REIMBURSEMENT FOR EXPENDITURES ON OFFICIAL BUSINESS 3. SCHEDULE NUMBER Read the Privacy Act Statement on the back of this form.

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