Application for Child's Insurance Benefits / Death Claim / Modernized Claims System (MCS) and Preliminary Claims System (PCS)

Application for Child's Insurance Benefits

PCS Screen Package

Application for Child's Insurance Benefits / Death Claim / Modernized Claims System (MCS) and Preliminary Claims System (PCS)

OMB: 0960-0010

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Preliminary Claims System (PCS)
Screen Package
Febryary 01, 2019

PCS Screen Package
February 01, 2019

Page 1 of 74

Table of Contents
1.

Individual Information – Individual applying on their own .................................................................................................... 4

2.

Individual Information – Individual applying on their own – Privacy Act Statement ............................................................... 5

3.

Individual Information – Individual answering questions not applying on their behalf ........................................................... 6

4.

Individual Information – Not the correct customer................................................................................................................ 7

5.

Individual Information – Third party applying on behalf of individual .................................................................................... 8

6.

Individual Information – Individual third party applying on behalf of customer ..................................................................... 9

7.

Individual Information – Organizational third party applying on behalf of customer ............................................................ 10

8.

Individual Information – Other third party applying on behalf of customer ......................................................................... 11

9.

Individual Information – Custodian or legal guardian applying on behalf of legally incompetent individual ......................... 12

10.

Individual Information – Custodian or legal guardian applying on behalf of legally competent customer ............................. 13

11.

Protective Filing – with one or more leads .......................................................................................................................... 14

12.

Protective Filing no lead – Yes ............................................................................................................................................ 16

13.

Protective Filing no lead – There is no previous protective filing date before today ............................................................. 17

14.

Person Information – Select “No” to add or update notice due to vision impairment .......................................................... 18

15.

Person Information – Select “Yes” to add or update notice due to vision impairment.......................................................... 20

16.

Person Information – Edit identity information ................................................................................................................... 22

17.

Person Information – Edit identity information: add other name ........................................................................................ 27

18.

Person Information – Edit identity information: add other name ........................................................................................ 28

19.

Person Information – Edit identity information: edit other name & error messages ............................................................ 29

20.

Person Information – Edit citizenship information .............................................................................................................. 30

20. Person Information – Edit citizenship information: Add citizenship......................................................................................... 31
20.1 Person Information – Edit citizenship information: Add citizenship ....................................................................................... 33
20.2 Person Information – Edit citizenship information: Add citizenship ....................................................................................... 34
23. Person Information – Edit contact information: U.S. primary phone number .......................................................................... 36
24. Person Information – Edit contact information: International primary phone number ............................................................ 39
24.1 Person Information – Edit contact information: Manage address.......................................................................................... 41
24.2 Person Information – Edit contact information: Manage address.......................................................................................... 42
25. Residence Address – Current mailing address is the same as residence address ...................................................................... 45
26. Residence Address – Current mailing address is different from residence address .................................................................. 46
27. Disability – “Yes” to all ........................................................................................................................................................... 49
28. Earnings – “Yes” to all ............................................................................................................................................................ 50
29. Earnings – “No” is selected .................................................................................................................................................... 56
30. Insured Status........................................................................................................................................................................ 59
31. Children – No children ........................................................................................................................................................... 61

PCS Screen Package
February 01, 2019

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32. Children – Children is selected ............................................................................................................................................... 62
33. Supplemental Security Income – Yes to all ............................................................................................................................. 63
34. Supplemental Security Income - Do not wish to apply for SSI ................................................................................................. 67
35. Benefits Summary – Default view (table) ............................................................................................................................... 68
36. Next Steps – Variations: file for all four benefit types ............................................................................................................. 71
37. Next Steps – Variations: set up an appointment for all four benefit types ............................................................................... 72
38. Next Steps – Variations: closeout for all four benefit types ..................................................................................................... 73
39. Next Steps – Variations: combination..................................................................................................................................... 74

PCS Screen Package
February 01, 2019

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1. Individual Information – Individual applying on their own

PCS Screen Package
February 01, 2019

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2. Individual Information – Individual applying on their own – Privacy Act Statement

PCS Screen Package
February 01, 2019

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3. Individual Information – Individual answering questions not applying on their behalf

PCS Screen Package
February 01, 2019

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4. Individual Information – Not the correct customer

PCS Screen Package
February 01, 2019

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5. Individual Information – Third party applying on behalf of individual

PCS Screen Package
February 01, 2019

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6. Individual Information – Individual third party applying on behalf of customer
Individual third party includes: spouse, parent, child, step parent, other family members, friend, and other relatives

PCS Screen Package
February 01, 2019

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7. Individual Information – Organizational third party applying on behalf of customer
Organizational third party includes: government agency, non-profit organizational/legal aid group, health service agency/hospital,
nursing care facility, non-related third party such as attorney, friend, advocacy group, legal entities, and attorney representatives.

PCS Screen Package
February 01, 2019

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8. Individual Information – Other third party applying on behalf of customer

PCS Screen Package
February 01, 2019

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9. Individual Information – Custodian or legal guardian applying on behalf of legally
incompetent individual

PCS Screen Package
February 01, 2019

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10.Individual Information – Custodian or legal guardian applying on behalf of legally
competent customer

PCS Screen Package
February 01, 2019

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11. Protective Filing – with one or more leads

PCS Screen Package
February 01, 2019

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PCS Screen Package
February 01, 2019

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12.Protective Filing no lead – Yes

PCS Screen Package
February 01, 2019

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13.Protective Filing no lead – There is no previous protective filing date before today

PCS Screen Package
February 01, 2019

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14.Person Information – Select “No” to add or update notice due to vision impairment

PCS Screen Package
February 01, 2019

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PCS Screen Package
February 01, 2019

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15.Person Information – Select “Yes” to add or update notice due to vision impairment

PCS Screen Package
February 01, 2019

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PCS Screen Package
February 01, 2019

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16.Person Information – Edit identity information

PCS Screen Package
February 01, 2019

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PCS Screen Package
February 01, 2019

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PCS Screen Package
February 01, 2019

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Note: The values in the drop-down list are from states GRT.

PCS Screen Package
February 01, 2019

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Note: This is the drop list for “Birth Date Proof”.

Note: This is the drop list for “Birth Date Proof Type”.

PCS Screen Package
February 01, 2019

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17. Person Information – Edit identity information: add other name
Select name type: Full name

PCS Screen Package
February 01, 2019

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18. Person Information – Edit identity information: add other name
Select name type: Single name

PCS Screen Package
February 01, 2019

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19. Person Information – Edit identity information: edit other name & error messages

PCS Screen Package
February 01, 2019

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20.Person Information – Edit citizenship information
Default view

PCS Screen Package
February 01, 2019

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20. Person Information – Edit citizenship information: Add citizenship
“Yes” to U.S. citizenship, “Yes” to citizenship ended.

PCS Screen Package
February 01, 2019

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PCS Screen Package
February 01, 2019

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20.1 Person Information – Edit citizenship information: Add citizenship
“Yes” to U.S. citizenship, “No” to citizenship ended.

PCS Screen Package
February 01, 2019

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20.2 Person Information – Edit citizenship information: Add citizenship
Not a U.S. citizen

PCS Screen Package
February 01, 2019

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Note: The values in the drop-down list are from the historical country GRT.

PCS Screen Package
February 01, 2019

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23. Person Information – Edit contact information: U.S. primary phone number

PCS Screen Package
February 01, 2019

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PCS Screen Package
February 01, 2019

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Note: The values in the drop-down list are from the language GRT.

Note: The values in the drop-down list are from the language GRT.

PCS Screen Package
February 01, 2019

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24. Person Information – Edit contact information: International primary phone number

PCS Screen Package
February 01, 2019

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PCS Screen Package
February 01, 2019

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24.1 Person Information – Edit contact information: Manage address
Select existing addresses

PCS Screen Package
February 01, 2019

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24.2 Person Information – Edit contact information: Manage address
Add new addresses and verify address

PCS Screen Package
February 01, 2019

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Note: The values in this drop-down list are from the country GRT.

PCS Screen Package
February 01, 2019

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Note: The values in the drop-down list are from the states GRT.

PCS Screen Package
February 01, 2019

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25. Residence Address – Current mailing address is the same as residence address

PCS Screen Package
February 01, 2019

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26. Residence Address – Current mailing address is different from residence address

PCS Screen Package
February 01, 2019

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Note: The values in the drop-down list are from the country GRT.

PCS Screen Package
February 01, 2019

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Note: The values in the drop-down list are from the states GRT.

PCS Screen Package
February 01, 2019

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27. Disability – “Yes” to all

PCS Screen Package
February 01, 2019

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28. Earnings – “Yes” to all

PCS Screen Package
February 01, 2019

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PCS Screen Package
February 01, 2019

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PCS Screen Package
February 01, 2019

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PCS Screen Package
February 01, 2019

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Note: the year drop down from the table will be dynamic based on the person's date of birth.

PCS Screen Package
February 01, 2019

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Note: The values in the drop-down list is from the historical country GRT.

PCS Screen Package
February 01, 2019

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29. Earnings – “No” is selected

PCS Screen Package
February 01, 2019

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PCS Screen Package
February 01, 2019

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PCS Screen Package
February 01, 2019

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30. Insured Status

PCS Screen Package
February 01, 2019

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PCS Screen Package
February 01, 2019

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31. Children – No children

PCS Screen Package
February 01, 2019

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32. Children – Children is selected

PCS Screen Package
February 01, 2019

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33. Supplemental Security Income – Yes to all

PCS Screen Package
February 01, 2019

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Note: This is the resources dropdown list.

PCS Screen Package
February 01, 2019

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Note: This is the income dropdown list.

PCS Screen Package
February 01, 2019

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PCS Screen Package
February 01, 2019

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34. Supplemental Security Income - Do not wish to apply for SSI

PCS Screen Package
February 01, 2019

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35. Benefits Summary – Default view (table)

PCS Screen Package
February 01, 2019

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PCS Screen Package
February 01, 2019

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PCS Screen Package
February 01, 2019

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36. Next Steps – Variations: file for all four benefit types

PCS Screen Package
February 01, 2019

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37. Next Steps – Variations: set up an appointment for all four benefit types

PCS Screen Package
February 01, 2019

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38. Next Steps – Variations: closeout for all four benefit types

PCS Screen Package
February 01, 2019

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39. Next Steps – Variations: combination

PCS Screen Package
February 01, 2019

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File Typeapplication/pdf
File TitleMicrosoft Word - PCS Screen Package 02012019
Author868865
File Modified2019-02-11
File Created2019-02-11

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