Union Security Life Insurance Company Details

If you are like most small business owners, you probably dread tax season. However, with the help of a qualified accountant, it doesn't have to be as daunting as it seems. One of the most common forms small businesses must file is Form C1275 1111. This form is used to calculate your net income for the year. With careful preparation and the right resources, filing your taxes can be a breeze. Let's take a closer look at what this form entails and how to complete it correctly.

Listed below are some specifics of form c1275 1111. There, you will get the details about the PDF you would like to fill out, including the estimated time required to complete it as well as other particulars.

QuestionAnswer
Form NameForm C1275 1111
Form Length4 pages
Fillable?Yes
Fillable fields119
Avg. time to fill out24 min 52 sec
Other namesNew_York, redisclosure, unearned, HIPAA

Form Preview Example

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

 

No

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

 

 

 

No

$

______________

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

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

 

 

No

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

 

 

No

$

______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

X

 

 

 

 

 

 

 

 

 

/

/

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

No

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I UNDERSTAND THAT:

 

 

 

 

 

 

 

 

 

 

 

a.

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.

 

 

 

 

 

 

 

 

 

 

 

b.

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).

 

 

 

 

c.

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

 

claim under my policy.

 

 

 

 

 

 

 

 

 

 

 

d.

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

 

 

 

 

 

 

e.

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

 

f.

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

 

alcohol/drug abuse and past medical history.

 

 

 

 

 

 

 

 

g.

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.

 

 

 

 

 

 

 

 

h.

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

 

 

 

 

 

 

i.

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

 

 

 

 

 

 

 

 

 

 

 

 

YOUR SIGNATURE (INSURED OR LEGAL REPRESENTATIVE)

 

 

 

 

 

DATE

 

X

 

 

 

 

 

 

 

 

 

 

/

/

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

How to Edit Form C1275 1111

Filling in the unearned file is a breeze using our PDF editor. Try out the following steps to create the document in a short time.

Step 1: Select the button "Get Form Here" and press it.

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Provide the data demanded by the program to get the document.

portion of gaps in HIPAA

Note the essential details in the area (INCLUDE PREFIX), INS, LOAN, APR, Simple Interest Precomputed, MO/DAY/YEAR / /, N O T A L U C L A C T F E N E B, Rule of 78s, Actuarial, Amount is after deduction of all, Yes, No , CITY, DATE OF BIRTH, and STATE ZIP CODE.

Completing HIPAA step 2

Describe the crucial details the (INCLUDE PREFIX), / / Yes No If yes, MO/DAY/YEAR / /, N O T A L U C L A C T F E N E B, ( ) Initial Amt, Term (Line 5), Monthly Decrease, Mos, Amount is after deduction of all, Yes, No , CITY, DATE OF BIRTH, STATE ZIP CODE, and DEALER NUMBER part.

HIPAA (INCLUDE PREFIX), / / Yes No If yes, MO/DAY/YEAR / /, N O T A L U C L A C T F E N E B, ( ) Initial Amt, Term (Line 5), Monthly Decrease, Mos, Amount is after deduction of all, Yes, No , CITY, DATE OF BIRTH, STATE ZIP CODE, and DEALER NUMBER fields to fill out

The INSURED INFORMATION NAME, STREET ADDRESS, SOCIAL SECURITY NUMBER, BIRTH DATE, CITY, DAYTIME TELEPHONE NUMBER ( ) STATE, ZIP CODE, MEDICAL PROVIDER (doctor, STREET ADDRESS, CITY, ZIP CODE, ENTIRE MEDICAL RECORD, HIV/AIDS TEST RESULTS OR DIAGNOSIS, DESCRIPTION OF INFORMATION TO BE, and Yes No field is where either side can place their rights and obligations.

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