Guide to Completing Life and Accidental Death Insurance Claims for Employers

Completing the Life and Accidental Death insurance claim form for employers. Employee/member demographic information. Employee’s division/location. These fields (name, date of birth, Social Security number, This is the location or division where the employee sex, address, marital status and occupation) are used to worked. This may be needed to determine the eligible identify the employee/member and to determine eligibility. class as per the policy. Was insurance issued on the basis of Policy class number. a statement of physical condition? Indicate the employee/member’s eligible class, as seen Indicate yes, only if the employee/member was required under the Schedule of Benefits. to provide evidence of insurability to New York Life Group Benefit Solutions (NYL GBS) prior to his or her Amount of insurance. approval for the requested amount of insurance. • Basic: This is the amount of insurance (in dollars) coverage for the employee/member. It should Check all of the boxes that apply to the be broken out by Basic Life, Voluntary Life and employee/member’s employment status Accidental Death, if applicable. and job classification. • Voluntary/Survivor Income Benefit insurance (SIBI): These fields are used to indicate the employee’s current Include enrollment forms or screen captures for work status and may help to determine if the employee Voluntary Life insurance for the prior three calendar meets the eligibility requirement in the policy. Check off years (including the current year). Provide original as many boxes as apply to the employee. If the employee enrollment information if the employee was not is part of a union, indicate the local union number. The required to re-enroll on a year-to-year basis. “hours worked” information should include the number of hours the employee worked on a weekly basis while he Date of hire. or she was an active employee. This information should This is the date the employee was hired for employment. correspond with the information pertaining to your This information is needed to ensure that the employee employee, as seen in the “classes of eligible employees” satisfied the eligibility waiting period for the policy. It may under the Schedule of Benefits in the policy. also pertain to certain employee class requirements. Note: An employee is considered active if he or she Effective date of insurance. is using a continuation option in an eligible class while This is the date the employee satisfied the eligibility out of work for an extended period of time. waiting period for his or her class. If the employee has voluntary life insurance, enter the effective date Basic annual earnings. of his or her most recent election to increase or This field is required if the benefit is based on the decrease coverage. employee’s annual salary. Refer to the definition of Date last worked. “annual compensation” in the policy. This is the last day the employee was physically at work Effective date of earnings. performing his or her normal duties. If this is a dependent This is the date of the employee’s most recent change in life claim, enter the date of the employee’s last day annual compensation. Refer to the definition of annual physically at work prior to the dependent’s death. If the compensation in the policy. You may also wish to refer to employee is still working, enter “current” in this field. the “effective date of insurance” and “automatic increase feauture” provisions to determine whether a recent salary increase has become effective.

Premium paid through date. Where and how did the accident happen? Date through which the employee/member’s If the employee/member died as a result of an accident premiums for all insurance coverages were paid. and has Accidental Death coverage, provide details about the accident and include copies of the police report, Has an assignment been taken? newspaper article, medical records and/or physician Indicate “yes” if an absolute or funeral assignment has statements, if available. been taken on the insurance coverage. Include a copy of the assignment with the claim. Beneficiary demographic information. In order to issue a payment to a beneficiary, provide the Was the employee actively at work until the name, address, date of birth and Social Security number date of the dependent’s death? as requested. It is important that we are notified of any Indicate if the employee was not working at the time of address changes while a claim is pending in our office. the death. This information is needed for employee and dependent claims. Disclosure authorization. The disclosure authorization should be signed by the If the employee was not actively at work beneficiary, next-of-kin or executor of the deceased’s immediately prior to his or her death or estate if basic and/or voluntary benefits are claimed dependent’s death, what was the reason? for a Life and/or Accidental Death claim. If the employee was not actively at work until his or her date of death, select the appropriate reason. The information in this field should correspond with the continuation options available in the employee’s eligible class and should reflect the reason for an employee’s M Questions? absence from work. Refer to the “continuation of insurance” provision in the policy for more information. Was coverage in effect through the date If you have questions about using of death? the claim form, call (800) 238-2125. If the employee’s coverage was not in effect at the time If you have questions about your of death, complete this field and indicate the reason why. claim, call (800) 362-4462. Is there a beneficiary designation on file for the employee/member? Include the most recent beneficiary designation completed by the employee/member. If the designation was done electronically, submit a screen capture of the beneficiary designation from the system that includes the beneficiary designation as well as the effective date. If a beneficiary designation is not available, check “No” in the field and refer to the “to whom payable” provision in your policy to determine the eligible recipient of the benefit. New York Life Group Benefit Solutions products and services are provided by Life Insurance Company of North America or New York Life Group Insurance Company of NY. Policy forms: Term Life -TL-004700 et al. New York Life Group Benefit Solutions products and services are provided by Life Insurance Company of North America and New York Life Group Insurance Company of NY, subsidiaries of New York Life Insurance Company. New York Life Insurance Company 51 Madison Avenue New York, NY 10010 © 2021, New York Life Insurance Company. All rights reserved. NEW YORK LIFE, and the NEW YORK LIFE Box Logo are trademarks of New York Life Insurance Company. 848743 a 0621 SMRU 1905145 Exp. Date 06.28.2023