Tsgli Claim Form – Fill Out and Use This PDF

GENERAL INFORMATION

The Servicemembers’ Group Life Insurance Traumatic Injury Protection (TSGLI) program is a rider to Service member’s Group Life Insurance (SGLI). The TSGLI rider provides for payment to service members who are severely injured (on or off duty) as the result of a traumatic event and suffer

a loss that qualifies for payment under TSGLI. TSGLI is designed to help traumatically injured service members and their families with financial burdens associated with recovering from a severe injury. TSGLI payments range from $25,000 to $100,000 based on the qualifying loss suffered.

WHO IS ELIGIBLE?

Effective December 1, 2005, all service members who are insured under SGLI and …

n experience a traumatic event

n that results in a traumatic injury

n which is listed as a qualifying loss

are eligible to receive a TSGLI payment. Service members who were severely injured between October 7, 2001, and November 30, 2005, in the theaters of operation for Operation Enduring Freedom or Operation Iraqi Freedom may also be eligible for a TSGLI payment. Members should contact their branch of service for more information.

What is a Traumatic Event?

A traumatic event is the application of external force, violence, chemical, biological, or radiological weapons, accidental ingestion of a contaminated substance, or exposure to the elements that causes damage to your body.

What is a Traumatic Injury?

A traumatic injury is the physical damage to your body that results from a traumatic event.

What is a Qualifying Loss?

A qualifying loss is a traumatic injury that is listed on the TSGLI Schedule of Losses, which lists all covered losses and payment amounts. You may view the complete Schedule of Losses and other TSGLI information at www.insurance.va.gov/sgliSite/TSGLI.htm Your branch of service TSGLI office will determine whether your injury is a qualifying loss for TSGLI purposes.

HOW TO FILE A TSGLI CLAIM

Filing a TSGLI claim is a three-step process in which the service member [or guardian, power of attorney or military trustee] and a medical professional must complete and submit the appropriate parts of the TSGLI Claim Form as follows:

Step 1	Step 2	Step 3
The service member [or guardian, power of	The medical professional…	The medical professional OR the service member [or
attorney or military trustee]…		guardian, power of attorney or military trustee]…
must complete Part A (pages 3 through 6) of the	must complete Part B (pages 7 through 12).	must forward Parts A & B to the member’s branch
form and give it to a medical professional to		of service TSGLI office listed on the front cover of
complete Part B. Note: If a guardian or power		this form.
of attorney completes Part A, they must include
copies of letters of guardianship, letters of
conservatorship, power of attorney, or durable
power of attorney (if appropriate).

SGLV 8600 Oct, 2008		*8732602*	Page 1
GL.2005.261 Ed. 10/2008
(Supersedes GL 2005.261	09/2005)

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COMPLETING THE FORM

Instructions on completing the TSGLI Claim Form are included in each section. When completing the form, the service member, guardian, power of attorney or military trustee must complete the service member’s Social Security number on each page of the form. If you have questions about completing the form or if the member is deceased, please contact the branch of service TSGLI office listed on the front cover of this form.

CLAIM DECISION AND PAYMENT

Who Makes the Decision on My Claim?

Your branch of service TSGLI office will make the decision on your claim based upon the information in Parts A and B of the TSGLI Claim Form. They will then forward their decision to the Office of Servicemembers’ Group Life Insurance (OSGLI) for appropriate action.

Who Will Receive the TSGLI Payment?

Payment will be made directly to the member. If the member is incompetent, payment will be made under the appropriate letters of guardianship/ conservatorship or a power of attorney to the guardian, power of attorney or military trustee on the member’s behalf. If the member dies after qualifying for payment, the payment will be made to the member’s current listed SGLI beneficiary(ies). The member must survive for seven days (168 hours) from the date of the traumatic event to be eligible for TSGLI.

How the TSGLI Payment Will be Made?

If your branch of service TSGLI office approves your claim, OSGLI will make the TSGLI benefit payment. There are three payment methods used for TSGLI benefits: Prudential’s Alliance Account®*, Electronic Funds Transfer (EFT), or check.

1.Prudential’s Alliance Account®* — (for member only) An interest-bearing account will be established in the name of the member. The member can access the money immediately using the draft book (“checkbook”). There are no monthly service fees or per-check charges and additional checks can be ordered at no additional cost. If you have any questions about Alliance, please call Alliance Customer Service toll free at 877-255-4262 or the OSGLI Claim Department toll free at 800-419-1473.

2.Electronic Funds Transfer (EFT) — Your bank account will be electronically credited with the TSGLI payment amount. Depending on your bank, payments will be credited three to five days from the date the payment is authorized.

Note: If the member does not choose EFT and there is no guardian, power of attorney or military trustee, the payment will be made through Prudential’s Alliance Account.

3.Check Payment — (for guardian, power of attorney or military trustee only) A check will be issued to the guardian or power of attorney or military trustee on behalf of the member.

RESPONDENT BURDEN: We need this information to allow service members who are insured under Servicemembers Group Life Insurance and suffer a loss from a traumatic injury to receive monetary compensation. Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 45 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.whitehouse.gov/omb/library/ OMBINV.html#VA. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this survey.

PRIVACY ACT NOTICE: VA will not disclose information collected on this survey to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses identified in the VA system of records , 36VA00, Veterans and Armed Forces Personnel U.S. Government Life Insurance Records-VA, and published in the Federal Register. Your obligation to respond is voluntary. Giving us your Social Security number account information is mandatory. Applicants are required to provide their Social Security number under Title 38 USC

1980A. VA will not deny an individual benefits for refusing to provide his or her Social Security number unless the disclosure is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect.

*Open Solutions BIS, Inc. is the Administrator of the Prudential Alliance Account Settlement Option, a contractual obligation of The Prudential Insurance Company of America, located at 751 Broad Street, Newark, NJ 07102-3777. Check clearing is provided by JPMorgan Chase Bank, N.A. and processing support is provided by Integrated Payment Systems, Inc. Alliance Account balances are not insured by the Federal Deposit Insurance Corporation (FDIC). Open Solutions BIS, Inc., JPMorgan Chase Bank, N.A., and Integrated Payment Systems, Inc. are not Prudential Financial companies.

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GL.2005.261 Ed. 10/2008
(Supersedes GL 2005.261	09/2005)

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PART A - Member’s Claim Information and Authorization - to be completed by the member, guardian, power of attorney or military trustee.

Service member’s Social Security Number

Address of Record (number and street)

Apt. (if any

Telephone Number

Important Note:

Contact information

must be completed.

City

State

ZIP Code

Incomplete information

will delay payment of

your claim.

E-mail Address

Unit (at time of injury)

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GL.2005.261 Ed. 10/2008
	(Supersedes GL 2005.261	09/2005)
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PART A - Member’s Claim Information and Authorization (cont’d) - to be completed by the member, guardian, power of attorney or military trustee.

Service member’s Social Security Number

If you are not sure…

whether your loss is a result of one of the items above, please contact your Branch of Service TSGLI Office to find out if you are eligible.

Tell us about your traumatic Injury

In the box below, please describe your injury and give the date, time and location where it occurred.

Traumatic Injury Information

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GL.2005.261 Ed. 10/2008
	(Supersedes GL 2005.261	09/2005)
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PART A - Member’s Claim Information and Authorization (cont’d) - to be completed by the member, guardian, power of attorney or military trustee.

Service member’s Social Security Number

Bank Routing Number

Bank Account Number

Check Number (not needed)

Description of Authority:

If the guardian, power

of attorney or military

X

trustee

completes this

section, they must also

Signature of service member, guardian, power of attorney or military trustee

Date (

MM DD YYYY

Description of Authority to

indicate their authority

)

act on behalf of the member

to act on behalf of the

WARNING: Any intentional false statement in this claim or willful misrepresentation relative thereto is subject to

(Guardian, POA, etc.)

member (e.g. guardian,

punishment by a fine of not more than $10,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001)

conservator, etc.)

Member must complete and sign the HIPAA release on next page t

SGLV 8600 Oct, 2008

*8732606*

Page 5

GL.2005.261

Ed. 10/2008

(Supersedes GL 2005.261 09/2005)

	*	8	7	3	2	6	0	6	*

PART A - Member’s Claim Information and Authorization (cont’d) - to be completed by the member, guardian, power of attorney or military trustee.

Service member’s Social Security Number