Americo Form is a company that provides medical devices to hospitals and clinics. In the past, Americo Form has been able to provide products for various clinical applications such as cardiology, ENT, orthopedics and neurology. Recently, they have released a new product called the Vascular Access Device which will allow patients with peripheral vascular disease or other circulatory conditions to receive dialysis treatments without being connected to a central line. This device eliminates the need for long-term catheter use which often leads to complications such as blood clots or infections. The Vascular Access Device allows physicians flexibility in choosing what type of treatment their patients should get because it can be used at home or in an outpatient clinic setting.
Before you complete americo form, you will need to learn more in regards to the type of form you will work with.
| Question | Answer |
|---|---|
| Form Name | Americo Form |
| Form Length | 8 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 2 min |
| Other names | americo insurance claims, americo insurance company forms, americo form, americo life insurance claims |
Death Claim Package for
Policy in Contestable Period
We offer our sincere condolences to the family in their recent loss. To begin processing the claim for benefits under this policy, we need the following documentation and forms completed and returned by the beneficiary.
CLAIMANT’S STATEMENT: Note: Must be signed by the Beneficiary and witnessed by a disinterested party or payment may be delayed. The claimant’s statement does not need to be notarized.
AUTHORIZATION: Note: Must be signed by the Executor(rix) of the Estate or the Next of Kin. If signed by Executor(rix) please include a copy of the Letters Testamentary.
HEALTH STATEMENT: Note: Must be completed by the Next of Kin with the most knowledge of the insured’s health history.
CERTIFIED COPY OF THE DEATH CERTIFICATE for the insured that identifies both cause and manner of death. Note: We cannot accept a photocopied death certificate for the insured person. A “certified” death certificate will have a “raised/embossed” or colored seal on the front. Generally, only one copy of the certified death certificate is necessary, even in the case of multiple beneficiaries. If any primary beneficiary
ORIGINAL INSURANCE POLICY: Note: Please be sure to mark the Claimant’s Statement where indicated if the policy is lost. If the claim is on a rider and the policy still provides coverage on additional individuals do NOT return the original policy. Please provide only a photocopy of the Policy Data Page and applicable insurance rider.
COPY OF THE OBITUARY (if available).
BENEFICIARY NAME CHANGE: Note: If the beneficiary’s name changed after the owner designated the beneficiary, please return documentation of the name change (Marriage Certificate, Divorce Decree, etc.)
Please mail these documents to Americo Financial Life & Annuity Insurance Company, Attn: Claims, at one of the following addresses:
Regular Mail: |
Overnight Mail: |
PO Box 410288 |
300 W. 11th. Street |
Kansas City, MO |
Kansas City, MO 64105 |
Other than the original Claimant’s Statement and Certified Death Certificate, faxed documents are generally acceptable and may be faxed to (800)
Because the death occurred during the contestable period, a routine investigation is necessary before a final determination can be made on this claim. To expedite the claim review and ensure prompt claim handling, please contact the Claims Department for information needed to properly complete the Health Statement. Proper completion of all forms will assist in avoiding delays in our review.
To assist with filing the claim, please read the Instructions to the Claimant Statement. If you have any additional questions or need further assistance, please contact our office at (800)
Sincerely,
Claims Department
Instructions & Claimant’s Statement
CLAIMANT’S STATEMENT must be completed by the person(s) to whom the insurance is payable. If there is more than one beneficiary, you may make copies of this form as needed.
Please allow 10 business days from the date we receive all required information for processing of payment.
When a policy is payable to the Estate, the Claimant’s Statement must be completed by the Executor(s) or Administrator(s), and submitted along with the Letters issued by the Court appointing that individual.
When a policy is payable to a company or corporation, the Claimant’s Statement must be signed by two officers and include each officer’s title.
When a policy is payable to a named beneficiary who is the age of majority or older, the statement must be made and signed by such beneficiary.
When a policy is payable to a minor, the statement may be made by the Court appointed Guardian of the minor’s Estate and submitted along with a copy of the Court issued appointment or in accordance with other applicable state law. Proceeds may also be held with the Company at interest until the minor reaches the age of majority, which varies by state.
If a policy has been collaterally assigned by the owner prior to the death of the insured, a Statement of Interest is also required. This document provides a statement of the assignee’s interest and may be obtained by contacting our office.
When an official inquiry as to the cause of death has been made, a certified copy of the medical report, verdict, or finding, must be furnished with this statement.
If any part of the proceeds of a policy is payable to “children” or to others of a designated class, an affidavit must be furnished giving the name and date of birth of each and stating that the persons named in the affidavit constitute all of the class designated in the policy. If any have died, the affidavit must give the date and place of death.
Form 712 may be requested at any time and will be provided upon completion of the claim payment.
PART A (INFORMATION ABOUT THE DECEASED)
Name of Deceased (State all names used by the deceased during their |
Policy Number(s) |
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life including maiden name, nickname, alias, or other name) |
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Deceased’s Date of Birth |
Deceased’s Social Security Number |
Date of Death |
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Deceased’s Place of Birth |
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Cause of Death |
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List all policy numbers with this company: |
If cause of death was other than natural: |
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Suicide |
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Homicide |
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Accident |
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PART B (INFORMATION ABOUT THE BENEFICIARY) |
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Beneficiary Name (First, Middle, Last)
Telephone Number
Mailing Street Address
City
State
ZIP
Beneficiary’s SSN/Tax ID#
Date of Birth (Mo/Day/Yr)
Relationship to Deceased
Americo Financial Life and Annuity Insurance Company • Home Office: Dallas, Texas • Administrative Office: PO BOX 410288, Kansas City, MO
By my signature below I certify, under penalty of perjury, that the Social Security Number/ Tax I.D. identified above is correct. I further certify that I am or I am NOT subject to backup withholdings because (a) I am exempt, or (b) I have not been notified by the Internal Revenue Service that I am subject to backup withholdings.
PART C (POLICY/DEATH CERTIFICATE) Please check the appropriate statements:
Enclosed is a certified copy of the death certificate of the insured. I have enclosed the original policy(ies).
After a diligent search, the original policy(ies), or copies, cannot be located
If beneficiary is a trust, I have enclosed trust documents, which shows successor trustee. If beneficiary is a trust, I certify that the trust is still in full force and effect.
Note: Failure to return the certified death certificate and to check the appropriate boxes in Part C may delay payment. Death certificates cannot be returned.
Settlement Options (Please check one of the following options, initial your selection, and sign below) Initial
Make proceeds immediately available*
I am interested in the Special Payment Options (e.g. Deposit, Installment or Life Income Options). Please send me additional information on these other options.
Other (please specify): ______________________________________________
FRAUD
Several States require that a notice be provided to each claimant to protect against Fraud. The undersigned acknowledge the Fraud Notice document has been received, read and is incorporated by reference if the state I reside in is listed on that notice. It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits.
The undersigned agrees that this statement constitutes claim for proceeds, if any, as was contractually in force at the time of the Deceased’s death and that furnishing of this form does not waive any contract provisions.
________________________________________ |
__________ |
________________________________________ |
__________ |
Disinterested Witness |
Date |
Beneficiary Signature |
Date |
________________________________________________________
Witness Address and Phone Number
MUST BE SIGNED BY A WITNESS
*Unless a lump sum payment is specifically requested, policy proceeds totaling $5,000 or more will be automatically settled by an interest- bearing Financial Access Account for your benefit. Upon approval of your claim, you will receive a book of personalized drafts, which may be used immediately to access some or all of the policy’s proceeds. You will have use of the account until your balance falls below $250, at which time it will be closed and the balance in the account plus accrued interest will be sent to you within 45 days. Although Financial Access Accounts are not FDIC insured, they are backed by the full strength and security of United Fidelity Life Insurance Company, the parent company of the life insurance companies owned or administered by Americo Life, Inc.
Americo Financial Life and Annuity Insurance Company • Home Office: Dallas, Texas • Administrative Office: PO BOX 410288, Kansas City, MO
Fraud Notice Form
Many states require the Insurer to provide claimants with a Fraud Statement such as the following:
Any person who, with intent to defraud or knowing that the person is facilitating a fraud against an Insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
The following states require the insurer to provide claimants with the specific language below:
ALASKA |
A person who knowingly and with intent to injure, defraud or deceive an insurance company files a claim containing |
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false, incomplete, or misleading information may be prosecuted under state law. |
CALIFORNIA |
For your protection, California law requires the following to appear on this form: |
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Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be |
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subject to fines and confinement in state prison. |
COLORADO |
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for |
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the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial |
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of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly |
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provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of |
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defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from |
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insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory |
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agencies. |
DELAWARE |
Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of claim |
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containing any false, incomplete, or misleading information is guilty of a felony. |
DISTRICT OF |
Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit |
COLUMBIA |
or who knowingly and willfully presents false information on an application for insurance is guilty of a crime |
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and may be subject to fines and confinement in prison. |
FLORIDA |
Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of claim or an |
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application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. |
IDAHO |
Any person who knowingly and with intent to defraud, or deceive any insurance company, files a statement |
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containing any false, incomplete, or misleading information is guilty of a felony. |
INDIANA |
A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, |
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incomplete or misleading information commits a felony. |
KENTUCKY |
Any person who knowingly and with intent to defraud any insurance company or other person files a statement of |
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claim containing any materially false information or conceals, for the purpose of misleading, information concerning |
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any fact material thereto commits a fraudulent insurance act, which is a crime. |
MAINE AND |
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the |
TENNESSEE |
purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. |
MARYLAND |
Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit |
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or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may |
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be subject to fines and confinement in prison. |
MINNESOTA AND |
A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. |
NEW HAMPSHIRE |
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NEW JERSEY |
Any person who knowingly files a statement of claim containing any false or misleading information is subject to |
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criminal and civil penalties. |
NEW YORK |
Any person who knowingly and with intent to defraud any insurance company or other person files an application for |
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insurance or statement of claim containing any materially false information, or conceals for the purpose of |
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misleading, information concerning any material thereto, commits a fraudulent insurance act, which is a crime and |
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shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each |
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such violation. |
OHIO |
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an |
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application or files a claim containing a false or deceptive statement is guilty of insurance fraud. |
Americo Financial Life and Annuity Insurance Company • Home Office: Dallas, Texas • Administrative Office: PO BOX 410288, Kansas City, MO
OKLAHOMA |
WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim |
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for the proceeds of an insurance policy containing false, incomplete, or misleading information is guilty of a felony. |
PENNSYLVANIA |
Any person who knowingly and with intent to defraud any insurance company or other person files an application for |
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insurance or statement of claim containing any materially false information, or conceals for the purpose of |
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misleading, information concerning any material thereto commits a fraudulent insurance act, which is a crime and |
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subjects such person to criminal and civil penalties. |
PUERTO RICO |
Any person who knowingly and with the intention to defraud, present false information in an application for insurance or, |
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who presents, helps to present or makes someone present a fraudulent claim for the payment of a loss or another |
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benefit, or who presents more than one claim for the same damage or loss, will incur a felony and if so convicted, |
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shall be sanctioned for each violation with a fine not less than five thousand ($5,000) dollars and not more than |
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ten thousand ($10,000) dollars, or a fixed jail term of three (3) years or both penalties. If there are aggravating |
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circumstances, the established fixed penalty may be increased up to a term of five (5) years; if there are |
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extenuating circumstances, it may be reduced to a minimum of (2) years. |
RHODE ISLAND |
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents |
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false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in |
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prison. |
TEXAS |
Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may |
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be subject to fines and confinement in state prison. |
WASHINGTON |
It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the |
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purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. |
Americo Financial Life and Annuity Insurance Company • Home Office: Dallas, Texas • Administrative Office: PO BOX 410288, Kansas City, MO
Health Statement
You can assist our office in handling this claim by completing the following information in full. To expedite the claim review and ensure prompt claim handling, please contact the Claims Department for information needed to properly complete the Health Statement. This form should be returned with the Claimant’s Statement and Certified Death Certificate.
1.List the name(s) and address(es) of the Decedent’s primary or family doctor. If the Decedent did not have a family doctor, please advise the name and address of the clinic/hospital where care would normally be sought:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
2. Did the Decedent have health insurance?..........................................................................................................................
Yes
No
If Yes, please provide the name(s) and address(es) of the carrier(s) and policy number(s): ______________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
3. Had the Decedent been in any hospital within the specified time period?..........................................................................
If yes, please provide name of hospital and dates of service:
Yes
No
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
4. Did the Decedent use any prescription medication prior to death? ....................................................................................
Yes
No
If Yes, what medicines? ___________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
5.What is the name and address of the pharmacy used to fill prescriptions? __________________________________________________
______________________________________________________________________________________________________________
6.The Decedent died as a result of:__________________________________________________________________________________
If the death resulted from illness or disease please provide the following:
A.Date the underlying condition causing death was first treated: ____________________________________________________
B.Name and address of doctor/clinic first treating: _______________________________________________________________
_______________________________________________________________________________________________________
7. To your knowledge did the Decedent smoke cigarettes or use other tobacco products prior to their death? ....................
Yes
No
If Yes, please list average quantity consumed: _________________________________________________________________________
Americo Financial Life and Annuity Insurance Company • Home Office: Dallas, Texas • Administrative Office: PO BOX 410288, Kansas City, MO
8. Did the Decedent use medication or receive treatment for:
A. Diabetes |
Yes |
B. Heart Disease |
Yes |
C. Stroke |
Yes |
D. Cancer |
Yes |
No |
E. Alzheimer’s Disease |
No |
F. Emphysema |
No |
G. Kidney Disease |
No |
H. Alcohol or Drug Treatment |
Yes
Yes
Yes
Yes
No
No
No
No
For any Yes response(s) above, please note the question letter and provide details about the prior care below.
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
9.Print the full name, address, and phone number of the Decedent’s employer: _______________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
10.Decedent’s occupation: ________________________________________________________________________________________
11.Date last worked: _____________________________________________________________________________________________
12.Facts concerning other life, health and accident insurance carried by the Decedent.
CompanyPolicy DateAmount of Insurance
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
I declare that the facts stated on this form are complete and true to the best of my knowledge and belief.
Warning: A person who knowingly and with intent to injure, defraud, or deceive an insurance company, files a claim containing false, incomplete or misleading information, may be guilty of a felony or misdemeanor.
_____________________________________________ |
_______________________________________ |
____________ |
Signature |
Relationship to Decedent |
Date |
Americo Financial Life and Annuity Insurance Company • Home Office: Dallas, Texas • Administrative Office: PO BOX 410288, Kansas City, MO
Authorization and Consent to Disclosure
This form is HIPAA compliant
Policy Number: ___________________________________________
Insured: ________________________________________________
Purpose of Authorization: Process Insurance Claim
HOME OFFICE USE ONLY
Records Provider
Name of Insured
Date of Birth
Social Security Number of Insured
Type of Records to be Released:
Time Period of Requested Records:
_________________________________________ to _________________________________________
I/We authorize any licensed physician, medical practitioner, hospital, clinic, pharmacy, or other medical related facility, insurance company, employer, Social Security Administration, the Medical Information Bureau (“MIB”), or any other person, organization or institution that may have records or information about me (our), or my (our) minor children who are insured to provide the Company, its authorized representative or its reinsurers, any and all medical (including entire medical, psychiatric/psychological, AIDS/AIDS related), alcohol and drug (including both illegal and prescription drugs) related records and information), criminal, and/or driving records or knowledge, to assist in determining insurability or eligibility for benefits.
The Company may release information obtained by this authorization to its reinsurers, to the MIB, to other insurers with whom I (we) have policies or to whom I (we) may submit a claim, to other persons performing business or legal services in connection with an insurance transaction for me (us) or as may otherwise be lawfully required. I/We understand that disclosure of information to the Company may subject the information to redisclosure in accordance with the Company’s privacy policy. It is the Company’s practice to prohibit third parties who lawfully receive nonpublic health information from redisclosing or
This authorization shall be valid for 24 months from the date of application. This authorization may be revoked; however, it may not be revoked to the extent that the Company has taken action in reliance on this authorization. Notice of revocation may be sent, in writing, to the Company at its Home Office address. A photocopy of this document shall be as valid as the original.
__________________________________________________________ |
_____________________ |
Signature (must be next of kin or Executor(rix) of Estate) |
Date |
__________________________________________________________ |
_____________________ |
Relationship |
Initial here if the Estate of the Insured |
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has not and will not be probated. |
Americo Financial Life and Annuity Insurance Company • Home Office: Dallas, Texas • Administrative Office: PO BOX 410288, Kansas City, MO