Form SSA-9309 Life Insurance Verification

FORM APPROVED

OMB No. 0960-0707

1

Social Security Administration

Office of Quality Assurance and

Performance Assessment

(Address of Office)

                                                                                                                   

Date:

RE:

(Address)

The Social Security Administration is conducting a quality review on some applications for extra help with Medicare prescription drug plan costs. We want to make sure that we have made the correct decision on these applications.

While reviewing the application filed by (fill-in 1), we were advised that (fill-in 2) has a life insurance policy with your company. We would appreciate it if you would provide the information requested on the enclosed form for the policy number(s) that we have shown, as well as any other policies that (fill-in 3) has with your company. Please provide the information effective with the month of (fill-in 4).

We have enclosed a signed authorization for release of the information, and a self-addressed stamped envelope for your convenience.

We appreciate your assistance with our review. If you have any questions, please call me at my office between 8:00 a.m. and 4:00 p.m., Monday through Friday. My toll-free telephone number is 1-800 ______.

Sincerely,

Social Insurance Specialist

Enclosures

PAPER REDUCTION ACT NOTICE

Paperwork Reduction Act Statement – This information collection meets the requirements of 44 U.S.C section 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 15 minutes to read the instructions, gather the facts, and answer the questions. Send only comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-0001.

PLEASE COMPLETE AND RETURN THIS FORM TO VERIFY ALL POLICIES FOR THE BENEFICIARY

AS OF: _______________

_______________________________ ____________________

Beneficiary’s Name Beneficiary’s SSN

	Policy 1	Policy 2	Policy 3	Policy 4
Policy Number
Owner of Policy
Type of Policy
Face Value	$	$	$	$
Outstanding Loan	$	$	$	$
Cash Surrender Value	$	$	$	$
Dividend Accumulations	$	$	$	$

Name:	Signature:
Company:	Telephone:
Address:	Date Completed:

QRA_________________

Life Insurance Verification

SSA-9309 (04-2007)