_______________________________
To Be Completed by Insured
Claim for Accelerated Benefits
Your name: _______________________________
Social Security Number: _______________________________
Your home address: _______________________________
Date of birth: _______________________________
Branch of Service (if covered under SGLI): _______________________________
Your mailing address (if different from above): _______________________________
Amount of SGLI coverage: $ _______________________________
Amount of claim (can be no more than one-half of coverage in increments of $5,000): _______________________________
Type of coverage (check one):
SGLI (circle one of the following): Active Duty Ready Reserve Army or Air National Guard Separated or Discharged
VGLI
Note: If you checked SGLI, you must also have your military unit complete the attached form.
I acknowledge that I have read all of the attached information about the accelerated benefit. I understand that I can get this benefit only once during my lifetime and that I can use it for any purpose I choose. I further understand that the face amount of my coverage will reduce by the amount of accelerated benefit I choose to receive now.
Your signature: _______________________________
Date: _______________________________
Authorization To Release Medical Records
To all physicians, hospitals, medical service providers, pharmacists, employers, other insurance companies, and all other agencies and organizations:
You are authorized to release a copy of all my medical records, including examinations, treatments, history, and prescriptions, to the Office of Servicemembers' Group Life Insurance (OSGLI) or its representatives.
Printed name: _______________________________
Signature: _______________________________
Date: _______________________________
A photocopy of this authorization will be considered as effective and valid as the original.
Valid for one year from date signed.
_______________________________
To Be Completed by Physician
Attending Physician's Certification
Patient's name: _______________________________
Patient's Social Security Number: _______________________________
Diagnosis: _______________________________
ICD-9-CM Disease Code *: _______________________________
Description of present medical condition (please attach results of x-rays, E.K.G. or other tests): _______________________________
Is the patient capable of handling his/her own affairs? ________ Yes____ No____
The patient applied for an accelerated benefit under his/her government life insurance coverage. To qualify, the patient must have a life expectancy of nine (9) months or less.
Does your patient meet this requirement? ________ Yes____ No____
Attending Physician's name (please print): _______________________________
State in which you are licensed to practice: _______________________________
Specialty: _______________________________
Mailing address: _______________________________
Telephone Number: _______________________________
Fax Number: _______________________________
Signature: _______________________________
Date: _______________________________
*ICD-9-CM is an acronym for International Classification of Diseases, 9th revision, Clinical Modification.
_______________________________
To Be Completed by Personnel Office of Servicemember's Unit
(Complete this form only if the applicant for Accelerated Benefits is covered under SGLI.)
Branch of Service Statement
Servicemember's name: _______________________________
Social Security Number: _______________________________
Branch of Service: _______________________________
Amount of SGLI coverage: $ _______________________________
Monthly premium amount: $ _______________________________
Name of person completing this form: _______________________________
Telephone Number: _______________________________
Fax Number: _______________________________
Title of person completing this form: _______________________________
Duty Station and address: _______________________________
Signature of person completing this form: _______________________________
Date: _______________________________
Notice: It is fraudulent to complete these forms with information you know to be false or to omit important facts. Criminal and/or civil penalties can result from such acts.
38 C.F.R. §9.14
Authority: 38 U.S.C. 1965 , 1966 , 1967 , 1980
Approved by the Office of Management and Budget under control number 2900-0618