American General Death Claim Form Details

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.

QuestionAnswer
Form NameAmerico Form
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other namesamerico insurance claims, americo insurance company forms, americo form, americo life insurance claims

Form Preview Example

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 pre-deceased the insured, we will require a photocopy of that beneficiary’s death certificate. Death certificates become part of the file and cannot be returned.

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 64141-0288

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) 395-9238.

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) 231-0801.

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)

life including maiden name, nickname, alias, or other name)

 

 

 

 

Deceased’s Date of Birth

Deceased’s Social Security Number

Date of Death

 

 

 

Deceased’s Place of Birth

 

Cause of Death

 

 

List all policy numbers with this company:

If cause of death was other than natural:

 

 

Suicide

 

 

Homicide

 

 

Accident

 

 

PART B (INFORMATION ABOUT THE BENEFICIARY)

 

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 64141-0288 • www.americo.com

04-005-2 (02/10)

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 64141-0288 • www.americo.com

04-005-2 (02/10)

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

 

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:

 

Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be

 

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

 

the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial

 

of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly

 

provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of

 

defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from

 

insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory

 

agencies.

DELAWARE

Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of claim

 

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

 

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

 

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

 

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,

 

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

 

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.

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

 

or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may

 

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

 

NEW JERSEY

Any person who knowingly files a statement of claim containing any false or misleading information is subject to

 

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

 

insurance or statement of claim containing any materially false information, or conceals for the purpose of

 

misleading, information concerning any 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.

OHIO

Any person who, with intent to defraud or knowing that he 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.

Americo Financial Life and Annuity Insurance Company • Home Office: Dallas, Texas • Administrative Office: PO BOX 410288, Kansas City, MO 64141-0288 • www.americo.com

04-005-2 (02/10)

OKLAHOMA

WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim

 

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

 

insurance or statement of claim containing any materially false information, or conceals for the purpose of

 

misleading, information concerning any material thereto commits a fraudulent insurance act, which is a crime and

 

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,

 

who presents, helps to present or makes someone present a fraudulent claim for the payment of a loss or another

 

benefit, or who presents more than one claim for the same damage or loss, will incur a felony and if so convicted,

 

shall be sanctioned for each violation with a fine not less than five thousand ($5,000) dollars and not more than

 

ten thousand ($10,000) dollars, or a fixed jail term of three (3) years or both penalties. If there are aggravating

 

circumstances, the established fixed penalty may be increased up to a term of five (5) years; if there are

 

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

 

false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in

 

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

 

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

 

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 64141-0288 • www.americo.com

04-005-2 (02/10)

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 64141-0288 • www.americo.com

04-005-2 (02/10)

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 64141-0288 • www.americo.com

04-005-2 (02/10)

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 re-using such information, except as may be done lawfully.

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

 

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 64141-0288 • www.americo.com

04-005-2 (02/10)

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .