Form C1275 1111 – Fill Out and Use This PDF

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.

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.

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:

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.

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

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

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

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.