Form Aglc100628 – Fill Out and Use This PDF

ACCIDENT AND HEALTH

INSURANCE CLAIM FORM

American General Life Insurance Company, Houston, TX

The United States Life Insurance Company in the City of New York, New York, NY

HOW TO SUBMIT YOUR CLAIM — PLEASE PRINT

STEP 1. Complete Part A below as it applies to this claim. Date and sign for all claims. STEP 2. Have your attending physician complete Part B.

STEP 3. When you and your attending physician have completed the form, in detail, attach the requested requirements and forward to us for review and processing to P.O. Box 4277, Houston, TX 77210-4277.

PART A TO BE COMPLETED BY INSURED

Please Note: Failure to complete this form IN FULL may delay the review of your claim.

1.	Policyholder Name __________________________________________						2. Policy Number(s)______________________
3.	Date of Birth ________________________________________________						4. Home Phone__________________________
5.	Home Address ______________________________________________						6. Office Phone __________________________
	____________________________________________________________
Complete for Spouse/Dependent
7.	Name ______________________________________________________						8. Date of Birth __________________________
9.	Full time student	l	Yes	l	No If “Yes”and 18 years or older submit proof of current school enrollment.

Complete for an Illness/Sickness Claim

Claim for Cancer: Submit the Pathology Report and Itemized bills

Claim for Hospital Confinement: Submit the Itemized Hospital bill

Claim for Critical Illness: Submit the medical records Re: Initial Diagnosis

10.Describe condition: ____________________________________________________________________________________

______________________________________________________________________________________________________

11. Date symptoms first noticed: ____________________ 12. Date first consulted physician ____________________

Complete for an Accident Claim

Requirements: The initial medical evaluation notes from emergency room, urgent care center or physician. The itemized bills and copies of the Explanation of Benefits from your major medical plan or other insurance coinciding with the bills you are submitting.

13.Date of accident __________________________

14.Where did accident happen? ____________________________________________________________________________

15.How did accident happen? ______________________________________________________________________________

________________________________________________________________________________________________________

16.Is the insured/dependent covered under any other group health insurance or service plan or federal medicare/medicaid program? l Yes l No

Date and Sign

17.I certify that the above information is true and correct. A photographic copy of this certification shall be considered as effective and valid as the original.

____________________________________________________________________________________	____________________
Signature of Policyholder	Date

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AGLC100628 Rev0911

PART B TO BE COMPLETED BY ATTENDING PHYSICIAN

1.Patient’s Name______________________________________________________ Date of Birth ____________________

2.Diagnosis and concurrent conditions: (Provide ICD-9 Code.)

______________________________________________________________________________________________________

______________________________________________________________________________________________________

3.Report of Services

DATE OF		PLACE OF	DESCRIPTION OF SURGICAL OR	CPT CODE
SERVICE		SERVICE*	MEDICAL SERVICE RENDERED
______________	__________________________		_____________________________________	____________________
______________	__________________________		_____________________________________	____________________
______________	__________________________		_____________________________________	____________________
______________	__________________________		_____________________________________	____________________
*0–Doctor’s Office		IH	–Inpatient Hospital	NH–Nursing Home
H–Patient’s Home		OH–Outpatient Hospital		OL–Other Locations

4.Date symptoms first appeared or accident happened. ____________________________________________________

5.Date patient first consulted you for this condition. ________________________________________________________

6. Has patient ever had same or similar condition? l No l Yes If “Yes” when and describe. ________________

______________________________________________________________________________________________________

7.Name of referring physician. ____________________________________________________________________________

8.Is patient covered under any Health Insurance / Service plan / Government Program? l No l Yes

Name of Carrier: ______________________________________________________________________________________

9. Was patient hospital confined? l No l Yes Name of Hospital__________________________________________

Provider Tax ID Number: ________________________________________________________________________________

Address ______________________________________________________________________________________________

This will confirm that the patient __________________________________________________(is/was) a patient in

this hospital and is charged room and board for ________days from__________________to ___________________.

Title: ____________________________________________Date		________________________________________________
Signature:	____________________________________________________________________________________________
DATE	SIGNATURE (Attending Physician)	TELEPHONE

PHYSICIAN’S NAME (Please Print)

STREET ADDRESS

CITY

STATE

ZIP CODE

IMPORTANT NOTICE

CALIFORNIA CLAIMANTS:

For your protection California law requires the following to appear on this form: “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 confinements in state prison.”

ALL OTHER CLAIMANTS:

A law of your state requires us to inform you that any person knowingly and with intent to defraud any insurance company or other persons 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 subjects such person to criminal and civil penalties.

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AGLC100628 Rev0911