Group Term Life - First Notice of Claim

Provident Claims Services, Inc.

PO Box 38295

Pittsburgh, PA 15238-8295

Toll-Free: 800.478.1752 | Fax: 412.963.0148

Email: claims@providentclaims.com

Business Hours: 8:30 AM to 5 PM

Please note, this document could take up to 15+ minutes to complete. If you wish to start filling it out now, you can always press "Save & Continue Later" at the bottom of this form to complete and submit at a later time.
Dear Beneficiary:

Please accept our condolences on your recent loss. We understand this is a difficult time, and we hope that we can alleviate any concerns you may have about your claim.

To help process your claim in the fastest possible manner, Provident Claims Services, Inc., on behalf of New York Life Insurance Company is providing this easy to use Claim Form for your convenience. Provident Claims Services, Inc., is a third-party administrator that performs claim administration for New York Life Insurance Company. Please review the form in its entirety, and then follow the step-by-step instructions to submit your claim.

Provident Claims Services, Inc., prides itself on the speed with which we pay claims. Please return the completed Claim Form, death certificate and any additional documents that we may request, so we can process your benefit promptly.*

Please be assured that Provident Claims Services, Inc., will act as quickly as possible to complete the processing of your claim once we receive all the necessary information and documentation. Please feel free to contact Provident Claims Services, Inc.’s claim center if you have any questions.

Mark E. Schmitt

President
CLAIM FORM FOR LIFE INSURANCE PROCEEDS
*This claim form may have been sent before Provident Claims Services, Inc., on behalf of New York Life has determined whether any insurance was in force at the time of death and to whom the proceeds are payable. New York Life retains the right to make such determination.

HOW TO COMPLETE YOUR CLAIM FORM

Please read this before you start to complete your Claim Form
To facilitate the processing of your claim, please send us a fully completed Claim Form from each beneficiary, one death certificate and any other documents that we may request. You may use a photocopy of the Claim Form if there is more than one beneficiary. No original documents will be returned.
GROUP CERTIFICATE INFORMATION
Please be sure to enter all certificate numbers on the Claim Form and enclose all the original insurance certificates, if available. If not available, please explain.

DECEASED INFORMATION
Information about the deceased is necessary for purposes of identification and benefit determination.

BENEFICIARY INFORMATION
Information about the Beneficiary is necessary for claims processing.

Taxpayer Identification Number: Life insurance benefits are generally not subject to income tax. However, New York Life pays interest on all proceeds from the date of death. Since the interest paid to you may be taxable, you should consult your tax advisor.

The Federal government requires us, and all other financial institutions, to report interest we pay you. Therefore, we are required to obtain your Social Security Number or Taxpayer Identification Number, which you must certify under penalties of perjury. If you are applying for a tax number, please write, “applied for” in the appropriate space. If you fail to supply us with an identification number, the Federal government requires us to withhold a portion of your interest as a deposit against the taxes that may be due.

Some persons have been notified by the Internal Revenue Service that they are subject to “backup withholding” because in the past they did not report all their interest or dividends. If you have been so notified, and a backup withholding order has not been rescinded, you must check the Backup Withholding statement right below your Income Tax Certification. We may contact you for more information if there are any questions about your Taxpayer Identification Number or backup withholdings status, or if you are a non-resident alien or foreign entity.
- Claims by an Estate: If an Executor or Administrator is filing the claim, he or she must sign the Claim Form and submit a certified copy of the appointment papers. Be sure to use the Tax Identification Number of the Estate. Note: A Last Will and Testament will not be accepted as proof of authority of executorship.
- Assignment: If you have assigned all or any portion of the claim to a funeral home for final expenses, please include a copy of that assignment. If the deceased assigned the policy proceeds to a bank or other financial institution, an authorized representative of that institution must sign the Claim Form.
- If the Beneficiary is a Minor: If there is a legal guardian for a minor, he or she should sign the Claim Form and submit a copy of the court document appointing the custodian of the minor child’s property/estate. If no legal guardian has been appointed, payment may be considered under the Uniform Transfers to Minors Act (UTMA) subject to state guidelines. Please contact our office for further information.
YOUR SIGNATURE
Please sign the Claim Form.

MEDICAL INFORMATION AND AUTHORIZATION
Complete this section ONLY IF all or any portion of life insurance coverage was issued within two years of the death of the insured, or if you are making a claim for an Accidental Death Benefit.

Illinois Interest Statement
If the certificate was issued in Illinois, you will be paid 10% interest, from the date of death, if your claim is not paid within 31 days of receiving the necessary proof needed to settle the claim.
Review our Important Notice Regarding Fraud before continuing:

YOUR SIGNATURE
I have read and understand the fraud warning in the “State Variations of Fraud Warnings” applicable to the state in which I reside. New York Residents: 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 five thousand dollars and the stated value of the claim for each such violation.

Under penalties of perjury, I certify: (1) My Social Security Number or Tax ID shown on this form is my correct taxpayer identification number, (2) I am not subject to backup withholding because a I am exempt from backup withholding; or (b) I have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all interest or dividend income; or (c) the IRS has notified me that I am no longer subject to backup withholding, (3) I am a U.S. person (includes a U.S. resident alien), and (4) The (FATCA) code entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. (Please note: if being submitted for a U.S. account, this last certification (4) does not apply.)
Check this box if the IRS has notified you that you are subject to backup withholding.
If you are not a U.S. citizen, U.S. resident alien or other U.S. person, you must submit the applicable Form W-8 with this form to certify your foreign status and, if applicable, claim treaty benefits.

If you are not a U.S. person, your signature below only applies to the provisions of this document other than the provisions contained in this Owner Tax Certification section.

The Internal Revenue Service does not require your consent to any provisions of this document other than the certifications required to avoid backup withholding.
Signature of Beneficiary*

Clear
Date*

MonthDayYear

MEDICAL INFORMATION AND AUTHORIZATION
HIPAA-Compliant Authorization

To expedite the processing of your claim, please complete this page in its entirety.

Complete if

(a) the death occurred within two years of the issue date or reinstatement date,

(b) the death was due to an accident and the policy contains the Accidental Death Benefit, or

(c) if specifically requested.
Physician #1 Information
Physician/Doctor Name
Physician Address
City
State
Zip Code
Physician Phone Number
Please enter a valid phone number.
Physician Visit Date(s):
Enter as many dates as needed.
Physician Condition(s) Note:
What condition(s) did the physician diagnose? Type as many as needed.
Physician #2 Information (if applicable)
Physician/Doctor Name
Physician Address
City
State
Zip Code
Physician Phone Number
Please enter a valid phone number.
Physician Visit Date(s):
Enter as many dates as needed.
Physician Condition(s) Note:
What condition(s) did the physician diagnose? Type as many as needed.
Physician #3 Information (if applicable)
Physician/Doctor Name
Physician Address
City
State
Zip Code
Physician Phone Number
Please enter a valid phone number.
Physician Visit Date(s):
Enter as many dates as needed.
Physician Condition(s) Note:
What condition(s) did the physician diagnose? Type as many as needed.
Physician #4 Information (if applicable)
Physician/Doctor Name
Physician Address
City
State
Zip Code
Physician Phone Number
Please enter a valid phone number.
Physician Visit Date(s):
Enter as many dates as needed.
Physician Condition(s) Note:
What condition(s) did the physician diagnose? Type as many as needed.
MEDICAL AUTHORIZATION:
I give my permission to release information concerning (Name of Insured)
Name of Insured
who died on

MonthDayYear
Death Date
to New York Life Insurance Company including its agents, affiliates or subsidiary companies and attorneys, reinsurers, insurance support groups and independent administrators who are acting on their behalf (“New York Life”). Information released may include records of medical advice, medical care, medical treatment of AIDS or AIDS-related diseases, mental illness, drug or alcohol use, other insurance coverage, financial and employment history, driving records, or information otherwise needed to determine policy claim benefits due but excludes psychotherapy notes. This information may be released by medical professionals or facilities, pharmacies, pharmacy benefit managers, government offices, employers, insurance companies, insurance support groups, group policyholders or benefit plan administrators, any consumer reporting agency, the Social Security Administration, the Internal Revenue Service, the Veteran’s Administration, or any other organization or person having any knowledge of the above-named Insured. When requesting information from any of the sources named above, a copy of this form is as valid as the original. I am aware that any information obtained will be used to evaluate my claim.

Either I, or a person I choose, am entitled to receive a copy of this authorization. This authorization is valid from the date signed until the claim is resolved, except in those states that allow for only a one-year limit.

I have the right to revoke this authorization at any time by notifying New York Life in writing at the address on this authorization. My revocation will not be effective to the extent New York Life or any other person already has disclosed or collected information or taken other action in reliance on this authorization. My revocation will also not be effective to the extent state law gives New York Life the right to contest a claim under the policy or the policy itself.

The information New York Life obtains based on this authorization may be subject to further disclosure. For example, New York Life may be required to provide it to insurance regulatory or other government agencies. In this case, the information may no longer be protected by the rules governing this authorization.
Signature for Medical Authorization

Clear
Relationship to Insured
Date

MonthDayYear
Should be Empty:

CLAIM FORM FOR LIFE INSURANCE PROCEEDS

HOW TO COMPLETE YOUR CLAIM FORM

ESO Admin Address:

Beneficiary Address:

YOUR SIGNATURE

MEDICAL INFORMATION AND AUTHORIZATION

Physician #1 Information

Physician #2 Information (if applicable)

Physician #3 Information (if applicable)

Physician #4 Information (if applicable)

MEDICAL AUTHORIZATION: