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.