Form SGLV8284 Servicemember's and Veterans' Group Life Insurance Accel

Servicemembers’ and Veterans’ Group Life Insurance

Accelerated Benefits Option

Administered by the
Office of Servicemembers’ Group Life Insurance
80 Livingston Avenue
Roseland, NJ 07068-1733
Toll-Free: 1-800-419-1473
Fax: (800) 236-6142

SGLV 8284, Edition 09/2007

Instructions For Submitting a Claim for Accelerated Benefits
About The Accelerated Benefit
The accelerated benefit allows you to receive up to 50% of your Servicemembers’ or Veterans’
Group Life Insurance if you have been diagnosed by your physician as being terminally ill (as
defined in Public Law 105-368) with nine (9) months or less to live. Only you (the insured) can
apply for this benefit.
The amount of insurance proceeds payable to your beneficiary(ies) at the time of your death will be
reduced by the amount of accelerated benefit you choose to receive now. Your premium will be
lowered to reflect the reduced amount of your coverage.

How To Claim This Benefit
To submit a claim for accelerated benefits, you, your physician and, if you’re covered under SGLI,
your branch of service must complete the attached forms as indicated at the top of each form. Once
all forms are completed, you should send the forms to:
OSGLI ABO Claim Processing
80 Livingston Avenue
Roseland, NJ 07068-1733

What You Should Know About Your Claim
You should be aware of the following before submitting your claim:
x Once we process your claim for accelerated benefits, we will send you a check for the amount
you request* and an explanation of the amount.
x Once you cash the payment, the accelerated benefit cannot be revoked.
x You can receive this benefit only once during your lifetime.
x You may use this benefit for any purpose you choose. Its use is not limited to medical expenses.
x If you’re covered under SGLI, OSGLI will notify your branch of service to reduce the face
amount of your coverage and your premium rate.
x If you die before cashing the accelerated benefit check, someone should return the check to
OSGLI.
x If your claim is not approved, we will notify you. You will then have the chance to submit
additional medical information. You can also reapply at a later date if you believe your condition
will qualify you for this benefit.
* The amount you request will be reduced by the amount of interest that would have been earned on it (over nine months)
had you not claimed it. Therefore, the check you receive will be less than the amount you claim.
If you have any questions, please call us toll-free at 1-800-419-1473. A customer service representative will assist you.
PRIVACY ACT STATEMENT - Title 38 U.S Code, Chapter 19, Subchapter III, Servicemembers' Group Life Insurance, authorizes solicitation of this information. This information is
needed to determine your eligibility for an "Accelerated Benefit Option" payment. Section 7701( c ) of Title 31, requires that any person doing business with the Federal Government
furnish a Social Security Number or tax identification number. An accelerated benefit will not be paid to you unless a completed application has been received by the Office of
Servicemembers' Group Life Insurance (Title 38, Section 1980).
RESPONDENT BURDEN - VA may not conduct or sponsor, and respondent is not required to respond to this collection of information unless it displays a valid OMB Control Number.
Public reporting burden for this collection of information is estimated to average 12 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have comments regarding this burden estimate or any other aspect of
this collection of information, call 1-800-419-1473 for mailing information on where to send your comments.

SGLV 8284, Edition 09/2007

OMB Control No.: 2900-0618
Respondent Burden: 12 minutes

To Be Completed By Insured
a) 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)

Type of coverage:
(check one)

Amount of SGLI
Coverage

Amount of Claim (can be
no more than one-half of
coverage)

$

$

SGLI (circle one of the following)
Active Duty

Ready Reserve

Army or Air National Guard

Separated or Discharged

VGLI
Note: If you checked SGLI, you must also have your military unit complete the attached form.

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 ___________________

b) 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.

SGLV 8284, Edition 09/2007

OMB Control No.: 2900-0618
Respondent Burden: 12 minutes

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

Mailing address

Telephone Number

Specialty

Fax Number

Signature ___________________________________________

Date ______________________

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

SGLV 8284, Edition 09/2007

OMB Control No.: 2900-0618
Respondent Burden: 12 minutes

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

Amount of SGLI Coverage

Monthly Premium Amount

$
Name of Person Completing This Form

$
Telephone Number

Title of Person Completing This Form

Duty Station and Address

Signature ________________________________________
of person
completing this form

Branch of Service

Fax Number

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.

SGLV 8284, Edition 09/2007