To Be Completed by Insured

Claim for Accelerated Benefits

Your name:

Social Security Number:

Your home address:

Date of birth:

Branch of Service (if covered under SGLI):

Your mailing address (if different from above):

Amount of SGLI coverage: $

Amount of claim (can be no more than one-half of coverage in increments of $5,000):

Type of coverage (check one):

SGLI (circle one of the following): Active Duty Ready Reserve Army or Air National Guard Separated or Discharged

VGLI

I acknowledge that I have read all of the attached information about the accelerated benefit. I understand that I can get this benefit only once during my lifetime and that I can use it for any purpose I choose. I further understand that the face amount of my coverage will reduce by the amount of accelerated benefit I choose to receive now.

Your signature:

Date:

Authorization To Release Medical Records

To all physicians, hospitals, medical service providers, pharmacists, employers, other insurance companies, and all other agencies and organizations:

You are authorized to release a copy of all my medical records, including examinations, treatments, history, and prescriptions, to the Office of Servicemembers' Group Life Insurance (OSGLI) or its representatives.

Printed name:

Signature:

Date:

A photocopy of this authorization will be considered as effective and valid as the original.

Valid for one year from date signed.

To Be Completed by Physician

Attending Physician's Certification

Patient's name:

Patient's Social Security Number:

Diagnosis:

ICD-9-CM Disease Code *:

Description of present medical condition (please attach results of x-rays, E.K.G. or other tests):

Is the patient capable of handling his/her own affairs? ____ Yes__ No__

The patient applied for an accelerated benefit under his/her government life insurance coverage. To qualify, the patient must have a life expectancy of nine (9) months or less.

Does your patient meet this requirement? ____ Yes__ No__

Attending Physician's name (please print):

State in which you are licensed to practice:

Specialty:

Mailing address:

Telephone number:

Fax Number:

Signature:

Date:

*ICD-9-CM is an acronym for International Classification of Diseases, 9th revision, Clinical Modification.

To Be Completed by Personnel Office of Servicemember's Unit

(Complete this form only if the applicant for Accelerated Benefits is covered under SGLI.)

Branch of Service Statement

Servicemember's name:

Social Security Number:

Branch of Service:

Amount of SGLI coverage: $

Monthly premium amount: $

Name of person completing this form:

Telephone Number:

Fax Number:

Title of person completing this form:

Duty Station and address:

Signature of person completing this form:

Date:

Notice: It is fraudulent to complete these forms with information you know to be false or to omit important facts. Criminal and/or civil penalties can result from such acts.