Application for Child's Insurance Benefits / Life Claim / MCS and PCS

Application for Child's Insurance Benefits

PCS Screen Package

Application for Child's Insurance Benefits / Life Claim / MCS and PCS

OMB: 0960-0010

Document [pdf]
Download: pdf | pdf
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

Page 2 of 74

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

Page 3 of 74

1. Individual Information – Individual applying on their own

PCS Screen Package
February 01, 2019

Page 4 of 74

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

PCS Screen Package
February 01, 2019

Page 5 of 74

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

PCS Screen Package
February 01, 2019

Page 6 of 74

4. Individual Information – Not the correct customer

PCS Screen Package
February 01, 2019

Page 7 of 74

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

PCS Screen Package
February 01, 2019

Page 8 of 74

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

Page 9 of 74

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

Page 10 of 74

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

PCS Screen Package
February 01, 2019

Page 11 of 74

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

PCS Screen Package
February 01, 2019

Page 12 of 74

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

PCS Screen Package
February 01, 2019

Page 13 of 74

11. Protective Filing – with one or more leads

PCS Screen Package
February 01, 2019

Page 14 of 74

PCS Screen Package
February 01, 2019

Page 15 of 74

12.Protective Filing no lead – Yes

PCS Screen Package
February 01, 2019

Page 16 of 74

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

PCS Screen Package
February 01, 2019

Page 17 of 74

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

PCS Screen Package
February 01, 2019

Page 18 of 74

PCS Screen Package
February 01, 2019

Page 19 of 74

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

PCS Screen Package
February 01, 2019

Page 20 of 74

PCS Screen Package
February 01, 2019

Page 21 of 74

16.Person Information – Edit identity information

PCS Screen Package
February 01, 2019

Page 22 of 74

PCS Screen Package
February 01, 2019

Page 23 of 74

PCS Screen Package
February 01, 2019

Page 24 of 74

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

PCS Screen Package
February 01, 2019

Page 25 of 74

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

Page 26 of 74

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

PCS Screen Package
February 01, 2019

Page 27 of 74

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

PCS Screen Package
February 01, 2019

Page 28 of 74

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

PCS Screen Package
February 01, 2019

Page 29 of 74

20.Person Information – Edit citizenship information
Default view

PCS Screen Package
February 01, 2019

Page 30 of 74

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

PCS Screen Package
February 01, 2019

Page 31 of 74

PCS Screen Package
February 01, 2019

Page 32 of 74

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

PCS Screen Package
February 01, 2019

Page 33 of 74

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

PCS Screen Package
February 01, 2019

Page 34 of 74

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

PCS Screen Package
February 01, 2019

Page 35 of 74

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

PCS Screen Package
February 01, 2019

Page 36 of 74

PCS Screen Package
February 01, 2019

Page 37 of 74

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

Page 38 of 74

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

PCS Screen Package
February 01, 2019

Page 39 of 74

PCS Screen Package
February 01, 2019

Page 40 of 74

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

PCS Screen Package
February 01, 2019

Page 41 of 74

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

PCS Screen Package
February 01, 2019

Page 42 of 74

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

PCS Screen Package
February 01, 2019

Page 43 of 74

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

PCS Screen Package
February 01, 2019

Page 44 of 74

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

PCS Screen Package
February 01, 2019

Page 45 of 74

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

PCS Screen Package
February 01, 2019

Page 46 of 74

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

PCS Screen Package
February 01, 2019

Page 47 of 74

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

PCS Screen Package
February 01, 2019

Page 48 of 74

27. Disability – “Yes” to all

PCS Screen Package
February 01, 2019

Page 49 of 74

28. Earnings – “Yes” to all

PCS Screen Package
February 01, 2019

Page 50 of 74

PCS Screen Package
February 01, 2019

Page 51 of 74

PCS Screen Package
February 01, 2019

Page 52 of 74

PCS Screen Package
February 01, 2019

Page 53 of 74

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

Page 54 of 74

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

PCS Screen Package
February 01, 2019

Page 55 of 74

29. Earnings – “No” is selected

PCS Screen Package
February 01, 2019

Page 56 of 74

PCS Screen Package
February 01, 2019

Page 57 of 74

PCS Screen Package
February 01, 2019

Page 58 of 74

30. Insured Status

PCS Screen Package
February 01, 2019

Page 59 of 74

PCS Screen Package
February 01, 2019

Page 60 of 74

31. Children – No children

PCS Screen Package
February 01, 2019

Page 61 of 74

32. Children – Children is selected

PCS Screen Package
February 01, 2019

Page 62 of 74

33. Supplemental Security Income – Yes to all

PCS Screen Package
February 01, 2019

Page 63 of 74

Note: This is the resources dropdown list.

PCS Screen Package
February 01, 2019

Page 64 of 74

Note: This is the income dropdown list.

PCS Screen Package
February 01, 2019

Page 65 of 74

PCS Screen Package
February 01, 2019

Page 66 of 74

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

PCS Screen Package
February 01, 2019

Page 67 of 74

35. Benefits Summary – Default view (table)

PCS Screen Package
February 01, 2019

Page 68 of 74

PCS Screen Package
February 01, 2019

Page 69 of 74

PCS Screen Package
February 01, 2019

Page 70 of 74

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

PCS Screen Package
February 01, 2019

Page 71 of 74

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

PCS Screen Package
February 01, 2019

Page 72 of 74

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

PCS Screen Package
February 01, 2019

Page 73 of 74

39. Next Steps – Variations: combination

PCS Screen Package
February 01, 2019

Page 74 of 74

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

© 2024 OMB.report | Privacy Policy