Group/Association - Proof of Loss: Life Insurance Accidental Death Insurance

Group/Association - Proof of Loss Life Insurance Accidental Death Insurance MAIL TO: New York Life Group Benefit Solutions Connecticut General Life Insurance Company P.O. Box 22328 Life Insurance Company of North America CLEAR FORM Pittsburgh, PA 15222-0328 New York Life Group Insurance Company of NY E-mail: claims.pghlif2@newyorklife.com Fax: 877-300-6770 NEW YORK FRAUD WARNING: 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 $5000 and the stated value of the claim for each such violation. CAUTION: Any person who, knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or statement of claim containing any materially false information; (2) conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act. For residents of the following states, please see the last page of this form: Arizona, California, Colorado, District of Columbia, Florida, Kansas, Kentucky, Louisiana, Maryland, Minnesota, New Jersey, Oregon, Pennsylvania, Puerto Rico, Rhode Island, Tennessee, Texas, Virginia or Washington. Instructions for Filing a Claim This form is for Life Insurance or Accidental Death proceeds only. Complete the form according to the instructions, to avoid delay or return i of the form. In boxes which contain the symbol , additional information is provided when hovering over the field to be completed. This feature is only available on the fillable version of this form. To The Employer/Administrator: 1. If claiming employee death benefits, please complete Sections A and C. If claiming dependent spouse or child benefits, please complete Sections A, B, and C. 2. If claiming voluntary or employee-paid benefits, please provide all of the enrollment history for the employee and the dependent (if claiming dependent benefits). 3. Please have each beneficiary review pages 1 through 7 and complete the appropriate pages. 4. Submit completed form to your assigned Claim Office with a Death Certificate, Beneficiary Designation and Enrollment Information, if applicable. Section A: Employee Information i Name of Employee/Member (Last Name) (First Name) (Middle Initial) Date of Birth Social Security Number Sex M F Address (Street) (City) (State) (Zip Code) Employee’s/Member’s Marital Status Single Married Widow/Widower Separated Divorced Domestic Partner Relationship Civil Union Policy Number(s): List all policies under which benefits are due. Occupation i Was insurance issued on the basis of a statement of physical condition? (If yes, attach copy) Yes No i Check all of the boxes that apply to the Employee/Member’s employment/membership status and job classification. Hours per week Active Exempt Management Supervisory Union Local Number Salaried Full-time Retired Non-Exempt Non-Management Non-Supervisory Non-Union Hourly Part-time i Basic Annual Earnings i Effective Date of Earnings i Employee’s Division/Location i Policy Class Number i Amount of Insurance: If claiming voluntary benefits, please provide enrollment information. Basic: AD&D (Please complete only if Basic: Life Voluntary: claiming AD&D benefits): Voluntary: SIB: BTA: i Has voluntary coverage for the employee/dependent been in effect continuously since enrollment? i Date Hired/Member i Effective Date of Yes No If No, please include enrollment history and enrollment forms if not already provided. of Assoc. Insurance i Date Last Worked Date of Death Cause of Death i Premium Paid Through Date i Has an assignment been taken? (If yes, attach copy) Yes No Was the above Considered an Employee/Association Member until i Was the Employee actively at work until the date of the Dependent’s death? his/her Date of Death? Yes No If No, Please Explain Yes No If No, indicate reason below. i If the Employee was not actively at work immediately prior to his/her death or Dependent’s death, what was the reason? Disability (STD) Paid Leave of Absence FMLA Temporary Layoff Resigned Minnesota Continuation (Please attach COBRA form.) Disability (LTD) Unpaid Leave of Absence Vacation Sabbatical Discharged Other: Was coverage still in effect through the Date of Death? If No, Please Explain Yes No i Is there a Beneficiary Designation on file for this Employee/Member? Yes No Please provide the most recent beneficiary designation with the claim. Please provide the Name of your Medical Insurance Carrier Beneficiary: please review and keep for your records. © 2023, New York Life Insurance Company, New York, NY. All rights reserved. NEW YORK LIFE and the New York Life box logo are registered trademarks of New York Life Insurance Company. Life Insurance Company of North America and New York Life Group Insurance Company of NY are subsidiaries of New York Life Insurance Company. Connecticut General Life Insurance Company is not affiliated with New York Life Insurance Company. Page 1 of 9 LMS-613500 Revised 10/2023