Application for Mother's of Father's Insurance Benefits Modernized Claims System (MCS) and Preliminary Claims System (PCS)

Application for Mother's or Father's Insurance Benefits

PCS Screen Package

Application for Mother's of Father's Insurance Benefits Modernized Claims System (MCS) and Preliminary Claims System (PCS)

OMB: 0960-0003

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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
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PCS Screen Package
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30. Insured Status

PCS Screen Package
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PCS Screen Package
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31. Children – No children

PCS Screen Package
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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
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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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