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