Form C1275 1111 – Fill Out and Use This PDF

The C1275 1111 form, associated with the Union Security Life Insurance Company of New York, serves as a Credit Life Death Claim Form, facilitating claims processing for benefits due to be paid directly to a creditor upon the insured's death. It outlines the necessity of completing specific sections and providing required documentation to avoid delays in processing claims. Key components include the need for a certified death certificate, creditor's statement, and if applicable, a statement of account at the date of death, among others. If you're navigating the complexities of filing a claim, ensure a seamless process by clicking the button below to fill out your form accurately.

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Form C1275 1111 PDF Details

When navigating the complexities of filing a credit life death claim, understanding the intricacies of the C1275 1111 form is paramount for beneficiaries under policies issued by Union Security Life Insurance Company of New York. This form serves as a central tool in initiating a claim following the debtor's demise, aiming to provide financial relief by directly paying off the outstanding balance to the creditor. The structured sections within the form, including personal details of the deceased, the certification of death, and specifics regarding the credit arrangement, underscore the necessity of meticulous completion to avert any processing delays. The inclusion of instructions for completion, alongside a stern warning about the ramifications of submitting fraudulent information, highlights the form's seriousness. Moreover, the necessity of attaching critical documents such as a certified death certificate, insurance certificate, and relevant financial statements cannot be overstated. With benefit payments destined directly to creditors, the form implicitly underlines the insurance's role in safeguarding financial interests posthumously. As such, satisfying the form's requirements — not limited to but including the completion of the Health Insurance Portability and Accountability Act (HIPAA) Authorization section — marked by sending the compiled dossier to the designated administrative office, becomes a crucial step toward claim resolution. The document's detailed acknowledgment of the claim's receipt and the outlined timeline for processing introduces an element of transparency and anticipation for beneficiaries steering through their grief and financial concerns.

Question	Answer
Form Name	Form C1275 1111
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	C1275-1111, redisclosure, unearned, Arizona

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Union Security Life Insurance Company of New York

Administrative Office

P.O. Box 977122, Miami, FL 33197-7122 1.877.438.7085 Fax 305.252.6910

Attn: DFS Claims Department

CREDIT LIFE DEATH CLAIM FORM

NET PAYOFF/CLOSED END MONTHLY OUTSTANDING BALANCE/

AD&D/GROSS DECREASING/LEVEL

All benefit payments are paid directly to your creditor.

IMPORTANT NOTICE

PLEASE READ CAREFULLY BEFORE COMPLETING YOUR CLAIM FORM

Failure to complete required sections and/or provide requested

documentation will delay processing of your claim.

INSTRUCTIONS FOR COMPLETING FORM

If the needed sections are not complete or if the attachments are not attached, the processing of the claim will be delayed. (Check box after each item is completed.)

1. Have person reporting claim complete Section B.

2. Attach a copy of the Certified Death Certificate.

3. Have Section C or D completed by your creditor or financial institution where the coverage was purchased. Complete Section C for Net/Payoff/Closed End Monthly Outstanding Balance

Complete Section D for AD&D, Gross Decreasing or Level

4. Attach a copy of Certificate of Insurance and Application for Credit Insurance, if applicable.

5. Attach Ledger Card or Statement of Account at date of death.

6. Complete attached Health Insurance Portability and Accountability Act (HIPAA) Authorization.

7. Follow your creditor’s instructions for mailing the completed claim form.

To avoid late fees, continue to make your payments until you receive notification that your claim has been approved.

Fax completed form and all supporting documentation to 305.252.6910 or mail to:

DFS Claims Department

PO Box 977122

Miami FL 33197-7122

ONCE YOUR CLAIM IS RECEIVED

YOU WILL RECEIVE A LETTER ACKNOWLEDGING RECEIPT OF YOUR CLAIM. THE LETTER WILL CONTAIN YOUR CLAIM NUMBER.

PLEASE ALLOW 15 BUSINESS DAYS FOR YOUR CLAIM TO BE PROCESSED.

AFTER YOUR CLAIM HAS BEEN PROCESSED, YOU WILL RECEIVE A LETTER ADVISING OF APPROVAL, DENIAL OR REQUEST FOR ADDITIONAL INFORMATION.

C1275-1111

Page 1 of 4

I1 LIFE/CRED-NY

Union Security Life Insurance Company of New York

Administrative Office

P.O. Box 977122, Miami, FL 33197-7122 1.877.438.7085 Fax 305.252.6910

Attn: DFS Claims Department

CREDIT LIFE DEATH CLAIM FORM

NET PAYOFF/CLOSED END MONTHLY OUTSTANDING BALANCE/

AD&D/GROSS DECREASING/LEVEL

A. DEATH CERTIFICATE

Attach a copy of the certified death certificate.

B. PERSON REPORTING CLAIM

PLEASE PRINT

This section must be completed if death occurred within 2 years of policy effective date.

Names and addresses of all physicians who attended deceased during last illness and during the five years prior to death:

NAME	STREET ADDRESS / CITY / STATE / ZIP CODE		TELEPHONE NUMBER	DATE OF ATTENDANCE		DISEASE OR CONDITION

		(	)	/	/
		(	)	/	/

AUTHORIZATION TO OBTAIN INFORMATION

I AUTHORIZE any employer, physician, hospital, clinic, other medical or medically related facility, the Medical Information Bureau, Inc., consumer reporting agency, insurance or reinsuring company, insurer, law enforcement agency, fire department, Social Security Administration, Internal Revenue Service, or other organization, or person having any records, data or information concerning this claim to furnish such record, data or information to the insurance company issuing my policy as requested. I understand that in executing this authorization, I waive the right for such information to be privileged as it pertains to the processing or investigation of my claim(s). A photocopy of this authorization shall be considered as effective and valid as the original.

I understand and acknowledge that this authorization extends to all or any part of the records being requested, which may include treatment for physical and mental illness, alcohol/drug abuse, and/or HIV/AIDS test results or diagnosis and treatment. I expressly consent to the release of information as designated above.

The above information is true and correct. If, in fact, the furnished information is false, thereby inducing payment of claim, and the insurance company issuing my policy determines that the incorrect information constitutes an aiding and abetting the filing of a fraudulent claim, the insurance company issuing my policy may furnish the above information to the appropriate state authorities to be used in its discretion as the basis for action authorized under applicable state law. In addition, I agree any statements made on this or any other form found to be false shall give to the insurance company issuing my policy the right to void my policy.

I, or my authorized representative, have the right to receive a copy of this authorization.

This authorization shall remain valid for the duration of the claim.

WARNING: 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.

PRINT NAME	SIGNATURE		RELATIONSHIP TO DECEASED			DATE
	X					/	/
STREET ADDRESS / APT #		CITY	STATE	ZIP CODE	TELEPHONE NUMBER
					(	)

C1275-1111

Page 2 of 4

CREDIT/DEATH-NY

C. CREDITOR’S STATEMENT - Net Payoff/Closed End Monthly Outstanding Balance

PLEASE PRINT

1. Please attach a copy of the Certified Death Certificate, Payoff Statement, Ledger Card, Insurance Certificate/Policy and Application for Credit Insurance, if applicable.

2. FULL NAME OF DECEASED

3. POLICY/CERTIFICATE NO.

4. DATE OF ISSUE

5. TERM (Mos)

6. LOAN

7. TYPE LOAN

8. AGENT CODE

9. INS. EXPIRES

(INCLUDE PREFIX)

MO/DAY/YEAR

INS.

LOAN

APR

Simple Interest

MO/DAY/YEAR

Precomputed

10. Health questions used

Yes

If yes, attach copy of completed application.

CALCULATION

11.

If Precomputed Loan (see item 7 above) — Check method of Interest Rebate:

Rule of 78s

Actuarial

12.

Initial amount of Insurance (Principal Amount of Loan)

______________

. . . . . . . .

. . .

. . . . . . . . . . . . . . .

. . . .

. . . . . . .

13.

Net Payoff Balance of Loan at Date of Death

BENEFIT

Amount is after deduction of all unearned credit insurance products other than credit life

Yes

______________

14.

Less any Principal Amount Included in Line 13 over 60 days delinquent

______________

. . .

. . . . . . . . . . . . . . .

. . . .

. . . . . . .

15.

Amount due to First Beneficiary (Creditor) (Line 13 minus Line 14) .

. . . . . . . .

. . .

. . . . . . . . . . . . . . .

. . . .

. . . . . . . .

______________

16.

Payments made, prior to but, not scheduled until after the date of death

. . .

. . . . . . . . . . . . . . .

. . . .

. . . . . . . .

______________

17. NAME OF SECOND BENEFICIARY

DATE OF BIRTH

18. STREET ADDRESS / APT #

CITY

STATE

ZIP CODE

19. NAME OF DEALER OR BRANCH WHERE INSURANCE WAS PURCHASED (if applicable)

DEALER NUMBER

20. FIRST BENEFICIARY / CREDITOR

FAX NUMBER

TELEPHONE NUMBER

(

)

(

)

21. STREET ADDRESS

CITY

STATE

ZIP CODE

22. NAME OF PERSON COMPLETING THIS SECTION (PLEASE PRINT)

SIGNATURE

DATE

D. CREDITOR’S STATEMENT – AD&D, Gross Decreasing or Level

PLEASE PRINT

1. Please attach a copy of the Certified Death Certificate, Payoff Statement, Ledger Card, Insurance Certificate/Policy and Application for Credit Insurance, if applicable.

2. FULL NAME OF DECEASED

3. POLICY/CERTIFICATE NO.	4. DATE OF ISSUE	5.TERM IN MONTHS 6. FIRST PAYMENT DUE DATE 7. POLICY/CERT. EXPIRES 8. AGENT CODE
(INCLUDE PREFIX)	MO/DAY/YEAR	MO/DAY/YEAR

9. Health questions used

Yes

If yes, attach copy of completed application.

CALCULATION

10.

Initial Amount of Insurance Coverage

. . . . .

. . . . . .

. . . . . . . .

. . . . . . .

. . . . . . . . . . . . . . . .

. . . . . . . . .

. . . . . . . .

______________

11.

If Decreasing Coverage, Amount of Decrease

(

) ÷ (

) =

(

) x (

)

. . . . . .

. . . . . . . .

______________

Initial Amt. (Line 10)

Term (Line 5)

Monthly Decrease

Mos. in Effect

12.

Amount of Insurance Coverage at Date of Death (Line 10 minus Line 11)

______________

BENEFIT

. . . . . . . . . . . . . . . .

. . . . . . . . .

. . . . . . .

13.

Less Amount claimed by First Beneficiary (Creditor) (Net Balance Due)

Amount is after deduction of all unearned credit insurance products other than credit life

Yes

______________

14.

Balance, if any, payable to Second Beneficiary (Line 12 minus Line 13)

. . . . . . . . . . . . . . . .

. . . . . . . . .

. . . . . . . .

______________

15. NAME OF SECOND BENEFICIARY

DATE OF BIRTH

16. STREET ADDRESS / APT #

CITY

STATE

ZIP CODE

17. NAME OF DEALER OR BRANCH WHERE INSURANCE WAS PURCHASED (if applicable)

DEALER NUMBER

18. FIRST BENEFICIARY / CREDITOR

FAX NUMBER

TELEPHONE NUMBER

(

)

(

)

19. STREET ADDRESS

CITY

STATE

ZIP CODE

20. NAME OF PERSON COMPLETING THIS SECTION (PLEASE PRINT)

SIGNATURE

DATE

C1275-1111

Page 3 of 4

CREDIT/DEATH-NY

Union Security Life Insurance Company of New York

Administrative Office

P.O. Box 977122, Miami, FL 33197-7122 1.877.438.7085 Fax 305.252.6910

Attn: DFS Claims Department

Authorization for Release of Protected Health Information

The Health Insurance Portability and Accountability Act (HIPAA) requires us to get your written permission to obtain specific health information about you. We are requesting this information in order to process the claim you are presenting to our company. Therefore, please complete in detail, sign, date, and return the following form to us. We cannot process your claim until we have this form returned to us.

I UNDERSTAND THAT THIS AUTHORIZATION IS VOLUNTARY

I hereby authorize the medical providers listed below to release the following information to Union Security Life Insurance Company of New York.

INSURED INFORMATION

NAME

SOCIAL SECURITY NUMBER

BIRTH DATE

DAYTIME TELEPHONE NUMBER

(

)

STREET ADDRESS

CITY

STATE

ZIP CODE

MEDICAL PROVIDER (doctor, hospital, etc.) WHO I AUTHORIZE TO RELEASE MY PERSONAL INFORMATION:

NAME

DAYTIME TELEPHONE NUMBER

(

)

STREET ADDRESS

CITY

STATE

ZIP CODE

DESCRIPTION OF INFORMATION TO BE RELEASED

ENTIRE MEDICAL RECORD

HIV/AIDS TEST RESULTS OR DIAGNOSIS AND TREATMENT

Yes

OTHER

I UNDERSTAND THAT:

This Authorization may be revoked by me at any time by writing to the company and clearly stating that I wish to revoke

this Authorization.

1. This Authorization will expire without any action by me one year after the date of my signing below.

2. This Authorization shall be valid for the duration of the claim (Arizona residents only).

Revocation will not apply to my insurance company when the law provides my insurance company the right to contest a

claim under my policy.

This authorization is voluntary and I have the right to refuse to sign it.

If I revoke this information, it will not apply to information that has already been released prior to my revocation.

Information released by this authorization may include information concerning treatment of physical and mental illness,

alcohol/drug abuse and past medical history.

Information released by this authorization may be subject to redisclosure by the recipient and may not be protected any

longer by the HIPAA Privacy Rule.

I agree that a photocopy of this authorization shall be as valid as the original.

I, or my authorized representative, have the right to receive a copy of this authorization.

YOUR SIGNATURE (INSURED OR LEGAL REPRESENTATIVE)

DATE

AND if signing on behalf of a minor or as legal representative of another:

NAME OF PERSON YOU ARE SIGNING FOR (PROOF OF YOUR AUTHORIZATION MAY BE REQUIRED)

ONE FORM MUST BE COMPLETED FOR EACH MEDICAL PROVIDER

Please photocopy this form if you need additional copies.

C1275-1111

Page 4 of 4

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filling out union security life insurance company part 1

Put the requested details in the C CREDITORS STATEMENT Net, FULL NAME OF DECEASED, POLICYCERTIFICATE NO, INCLUDE PREFIX, DATE OF ISSUE MODAYYEAR, TERM Mos, INS, LOAN, LOAN APR, TYPE LOAN, AGENT CODE, INS EXPIRES, Simple Interest Precomputed, MODAYYEAR, and Health questions used Yes No If field.

Filling out union security life insurance company step 2

The program will request information to quickly submit the section STREET ADDRESS, NAME OF PERSON COMPLETING THIS, FAX NUMBER CITY, SIGNATURE X, STATE ZIP CODE, DATE, D CREDITORS STATEMENT ADD Gross, PLEASE PRINT, FULL NAME OF DECEASED, POLICYCERTIFICATE NO, INCLUDE PREFIX, Health questions used, DATE OF ISSUE MODAYYEAR, Yes No If yes attach copy of, and MODAYYEAR.

Finishing union security life insurance company part 3

Describe the rights and obligations of the parties inside the field STREET ADDRESS APT, CITY, STATE ZIP CODE, NAME OF DEALER OR BRANCH WHERE, DEALER NUMBER, FIRST BENEFICIARY CREDITOR, STREET ADDRESS, NAME OF PERSON COMPLETING THIS, FAX NUMBER CITY, SIGNATURE X, TELEPHONE NUMBER, STATE ZIP CODE, DATE, Page of, and CREDITDEATHNY.

step 4 to entering details in union security life insurance company

Look at the sections INSURED INFORMATION NAME, STREET ADDRESS, SOCIAL SECURITY NUMBER, BIRTH DATE, CITY, DAYTIME TELEPHONE NUMBER STATE, ZIP CODE, MEDICAL PROVIDER doctor hospital, STREET ADDRESS, ZIP CODE, CITY, ENTIRE MEDICAL RECORD, HIVAIDS TEST RESULTS OR DIAGNOSIS, DESCRIPTION OF INFORMATION TO BE, and Yes No and then complete them.

part 5 to filling out union security life insurance company

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