Form SGLV 8284 SGLV 8284 Servicemember's and Veterans Group Life Insurance Accele

Claim for Accelerated Benefits
Servicemembers’ Group Life Insurance (SGLI)
Veterans’ Group Life Insurance (VGLI)
About the Accelerated Benefit Option
The Accelerated Benefit Option allows you to receive up to 50% of your SGLI or VGLI benefit if you have been diagnosed by your physician
as being terminally ill (as defined in Public Law 105-368) with nine (9) months or less to live. Only you (the insured) can apply for this benefit.
The amount of insurance proceeds payable to your beneficiaries at the time of your death will be reduced by the amount of accelerated
benefit you choose to receive now. Your premium will be lowered to reflect your reduced coverage amount.
How to Submit a Claim for Accelerated Benefits
You, your physician and, if you’re covered under SGLI, your branch of service must complete the attached forms as indicated. Completed
forms should be submitted as follows:
Active duty service members/Reservists

Army National Guard

Veterans

Submit completed forms to your branch of
service personnel office.

Contact your state headquarters for submission
instructions.

Submit completed forms to:
The Prudential Insurance Company of America
PO Box 70173
Philadelphia, PA 19176-0173
Fax: 877-832-4943

Important Information
■■

If your claim for accelerated benefits is approved, you will receive a check for the amount requested.

■■

Once the payment is cashed, the accelerated benefit cannot be revoked.

■■

You can receive this benefit only once during your lifetime.

■■

You may use this benefit for any purpose you choose.

■■

If you’re covered under SGLI, the Office of Servicemembers’ Group Life Insurance (OSGLI) will notify your branch of service to reduce
the face amount of your coverage and your premium rate.

■■

If you die before cashing the accelerated benefit check, your next of kin should return the check to OSGLI.

■■

If your claim is not approved, you have the option of submitting additional medical information or reapplying at a later date.

SGLV 8284

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OMB Control No.: 2900-0618
Respondent Burden: 12 minutes
Expiration Date: xx/xx/xxxx
PRIVACY ACT INFORMATION: VA will not disclose information collected on this form to any source other than what
has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses identified
in the VA system of records, 36VA29, Veterans and Uniformed Services Personnel Programs of U.S. Government Life
Insurance - VA, and published in the Federal Register. Your obligation to respond is voluntary. VA uses your SSN to identify
your insurance file. Providing your SSN will help ensure that your records are properly associated with your insurance file.
Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of
benefits. The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN
is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect.

TO BE COMPLETED BY SERVICE MEMBER OR VETERAN

CLAIM FOR ACCELERATED BENEFITS
Social Security Number

Name (first middle last)
Home address

Date of birth
(mm/dd/yyyy)

Branch of Service
(if covered under SGLI)

Mailing address
(if different from home address)

Amount of
SGLI/VGLI coverage
$

Amount of claim
(Cannot exceed 50% of your total coverage)
$

Telephone Number

Email Address (Your email address is being requested so that we can
provide you with a tracking number once your claim has been processed)

Type of coverage (check one)

VGLI
SGLI (if covered under SGLI, indicate your current status)
Active Duty
Ready Reserve
Army or Air National Guard
Separated or Discharged

Important: If you checked SGLI, your branch of service personnel office must complete page 4.

I acknowledge that I have read all of the attached information about the accelerated benefit. I understand that I can get this benefit only
once during my lifetime and that I can use it for any purpose I choose. I further understand that the face amount of my coverage will reduce
by the amount of accelerated benefit I choose to receive now.
Signature _________________________________________________ Date Signed _____________________

AUTHORIZATION TO RELEASE MEDICAL RECORDS
To all physicians, hospitals, medical service providers, pharmacists, employers, other insurance companies, and all other agencies
and organizations:
You are authorized to release a copy of all my medical records, including examinations, treatments, history, and prescriptions, to the
Office of Servicemembers’ Group Life Insurance (OSGLI) or its representatives.
Print Name _______________________________________________
Signature ________________________________________________ Date Signed _____________________
A photocopy of this authorization will be considered as effective and valid as the original. Valid for one year from date signed.

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TO BE COMPLETED BY SERVICE MEMBER’S OR VETERAN’S PHYSICIAN

ATTENDING PHYSICIAN’S CERTIFICATION
Patient’s name

Diagnosis

Patient’s Social Security Number

ICD-9-CM/ICD-10-CM Disease Code*

Description of Present Medical Condition (Please attach any supporting documentation such as x-rays, E.K.G. results, or test results.)

Do you feel the claimant is competent to endorse checks and direct the use of the proceeds.
Yes
No
The patient applied for an accelerated benefit under his/her government life insurance coverage. To qualify, the patient must have a life
Yes
No
expectancy of nine (9) months or less. Does your patient meet this requirement?
Attending physician’s name
(please print)

State in which you are
licensed to practice

Specialty

Mailing address

Fax number

Telephone number

Signature _________________________________________________ Date Signed ____________________

*International Classification of Diseases, 9th revision, Clinical Modification/International Classification of Diseases,
10th revision, Clinical Modification

SGLV 8284

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TO BE COMPLETED BY THE PERSONNEL OFFICE OF THE SERVICE MEMBER’S UNIT
Complete only if the applicant for accelerated benefits has SGLI coverage.

BRANCH OF SERVICE STATEMENT
Service member’s name

Social Security Number

Amount of SGLI coverage
$ 250,000

Monthly premium amount
$

50,000
100,000
150,000
200,000
300,000
350,000
400,000
Name and title of person completing this form

Telephone number

Branch of Service

Fax number

Duty station and address

Signature of person completing this form

Date

Note: After completing this section, the personnel officer should submit the form to the service member’s casualty branch.

TO BE COMPLETED BY THE SERVICE MEMBER’S CASUALTY BRANCH
Certified by:
Name

Title

Branch of Service

Certification date

Telephone number

Fax number

Notice: It is fraudulent to complete these forms with information you know to be false or to omit important facts. Criminal and/or civil
penalties can result from such acts.

SGLV 8284 Page 4 of 4