CRITICAL ILLNESS CLAIMS
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1 CRITICAL ILLNESS CLAIMS 777 Research Drive, Lincoln, NE Claim Instructions To report a Group Critical Illness claim, please contact our claims department at , Option 5 or else write to us at: 5Star Life Insurance Company Attn: CI Claims Dept. 777 Research Drive Lincoln, NE Please be prepared to provide the claimant's name, policy number, employer group, and the specific condition and date of diagnosis for which you are claiming benefits as well as a daytime phone number where you can be reached. One of our claims representatives will contact you with further instructions for completing your claim. You may also fill in the questionnaire on the following pages and submit to the address above. CI ClaimForm 4/2014
2 Administrative Office: PO Box 83043, Lincoln, NE PERSONAL INFORMATION CRITICAL ILLNESS CLAIM QUESTIONNAIRE TO BE COMPLETED BY CLAIMANT Name: Policy Number: Date of Birth: Telephone: Home: ( ) Office: ( ) Cell: ( ) Address: 2. DETAILS OF CRITICAL ILLNESS a) Please describe your illness: Date of diagnosis or operation b) When did the first symptoms appear? Please describe the symptoms: c) When did you first consult a Physician for this condition? d) Name & address of that attending Physician: e) Please provide details and dates of tests or exams to confirm the diagnosis. f) Did you previously suffer from or receive treatment for the same or a similar condition? If yes, please provide details and dates: Page 1 of 5
3 Name: Policy Number: Date of Birth: 3. MEDICAL CONSULTATIONS a) Name and address of your personal Physician: b) Names, addresses and dates seen of any other Physicians or Specialists consulted for this disease: c) Names, addresses, dates admitted and discharged from any hospitals or other medical facilities: d) Describe current and past treatments for this disease: Type of treatment Hospital/Institution/Treating Physician Dates 4. GENERAL INFORMATION a) Has anyone in your direct family (parents or siblings) suffered from this or similar disease? If yes, please provide: Relationship Disease Age when first diagnosed b) Please provide any other information that may be useful in the assessment of your claim. Page 2 of 5
4 Name: Policy Number: Date of Birth: 5. DECLARATION AND AUTHORIZATION AUTHORIZATION TO OBTAIN INFORMATION: I hereby authorize any physician or practitioner of the healing arts who has examined or treated me, and all hospitals, clinics or medically related facilities, insurance companies, health maintenance organizations, medical information bureau, government entity (federal, state or local) or other organization, institution or person, that has any information, records or knowledge of me or my health, past or present, to furnish to 5Star Life Insurance Company (or its representatives) and to permit them to examine and copy any such information. I understand that 5Star Life Insurance Company may disclose the information in connection with underwriting or claims processing with the company. A copy of this authorization, or the original, shall be valid for ninety (90) days from the date signed. I acknowledge that I have a right to a copy of this authorization upon request. Signature: Date: Name Printed: Policy Number: Date of Birth: Page 3 of 5
5 State Specific Fraud Language for Claim Forms ALASKA Pursuant to Alaska Insurance Statutes and Regulations, A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete or misleading information may be prosecuted under state law. ARKANSAS Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement imprison. ARIZONA For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. CALIFORNIA For your protection California law required the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. COLORADO Pursuant to Colorado Insurance Statutes and Regulations, It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. DISTRICT OF COLUMBIA WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. DELAWARE Pursuant to Delaware Insurance Statutes and Regulations, Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. FLORIDA Pursuant to Florida Insurance Statutes and Regulations, Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty or a felony of the third degree. IDAHO Pursuant to Idaho Insurance Statutes and Regulations, Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement containing any false, incomplete, or misleading information is guilty of a felony. INDIANA Pursuant to Indiana Insurance Statutes and Regulations, A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony. KENTUCKY Pursuant to Kentucky Insurance Statutes and Regulations, Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. LOUISIANA Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. MAINE It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. Page 4 of 5
6 MINNESOTA Pursuant to Minnesota Insurance Statutes and Regulations, A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. NEW HAMPSHIRE Pursuant to New Hampshire Insurance Statutes and Regulations, Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution of punishment and insurance fraud, as provided in RSA 638:20. NEW JERSEY Pursuant to New Jersey Insurance Statutes and Regulations, Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. NEW MEXICO Pursuant to New Mexico Insurance Statutes and Regulations, Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. NEW YORK Pursuant to New York Insurance Statutes and Regulations, 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 civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. OHIO Pursuant to Ohio Insurance Statutes and Regulation, Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. OKLAHOMA Pursuant to Oklahoma Insurance Statutes and Regulations, WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. PENNSYLVANIA Pursuant to Pennsylvania Insurance Statutes and Regulations, 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 fraudulent insurance act, which is a crime and subjects such person criminal and civil penalties. TENNESSEE It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. TEXAS Any person who knowingly presents a false or fraudulent claim for the payment of loss is guilty of a crime and may be subject to fines and confinement in state prison. VIRGINIA It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. WEST VIRGINIA Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Page 5 of 5
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