Form SGLV 8600 SGLV 8600 Application for TSGLI Benefits

Servicemembers' Group Life Insurance – Traumatic Injury Protection Program (TSGLI) Application for TSGLIL Benefits (SGLV 8600) AND TSGLI Appeal Request Form (SGLV 8600a)

SGLV 8600

Servicemembers' Group Life Insurance – Traumatic Injury Protection Program (TSGLI) Application for TSGLIL Benefits (SGLV 8600) AND TSGLI Appeal Request Form (SGLV 8600a)

OMB: 2900-0919

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 2900-0919 can be found here:

2023-03-03 - Extension without change of a currently approved collection

Document [pdf]

Download: pdf | pdf

SERVICEMEMBERS’ GROUP LIFE INSURANCE TRAUMATIC
INJURY PROTECTION PROGRAM (TSGLI)
Administered by the Office of Servicemembers’ Group Life Insurance

Application for TSGLI Benefits
Please submit your completed claim to your branch of service below.
TSGLI Branch of Service Contacts
Branch

Contact Information

Submit Claim by Fax

Submit Claim by Email

Submit Claim by Postal Mail

Army
All Components

Phone: 888-276-9472
Website: www.hrc.army.mil/content/
Traumatic Servicemembers’ Group Life
Insurance

502-613-4513

usarmy.knox.hrc.mbx.tagd-tsgli-claims
@mail.mil

US Army Human Resources Command
1600 Spearhead Division Avenue,
Dept 420 PDR-C (TSGLI)
Fort Knox, KY 40122-5402

Marine Corps
All Components

Phone: 877-216-0825 or 703-975-4069
Website:
www.woundedwarrior.marines.mil

800-770-9968

[email protected]

HQ, Marine Corps
Attn: WWR-TSGLI
1998 Hill Street
Quantico, VA 22134

Navy
All Components

Phone: 1-877-270-2162
Website: www.mynavyhr.navy.mil/
Support-Services/Casualty/TSGLI/

901-874-2265

[email protected]

Commander, Navy Personnel Command
Attn: PERS-00C
5720 Integrity Drive
Millington, TN 38055-1300

Air Force and
Space Force
Active Duty

Phone: 800-525-0102, Option 1, Option 1

AFPC.DPFCS.Pol_Trng_CaseMgt@
us.af.mil

AFPC/DPFCS
550 C Street West, Suite 14
Randolph AFB, TX 78150-4716

Air Force
Reserves and
Air National
Guard

Phone: 800-525-0102, Option 3, Option 1

[email protected]

HQ, ARPC/DPTTB
18420 E. Silver Creek Ave.
Building 390 MS 68
Buckley AFB, CO 80011

Coast Guard

Phone: 202-795-6638
Website:
www.dcms.uscg.mil/PSD/fs/TSGLI

[email protected]

Commander (CG)
Personnel Service Center (PSC)
Attn: TSGLI Case Manager,
PSC-PSD-FS-Casualty
U.S. Coast Guard STOP 7200
2703 Martin Luther King Jr Ave SE
Washington, DC 20593-7200

Public Health
Service

Phone: 240-276-8799

240-276-8817 or
240-453-6030

[email protected]

PHS Compensation Branch
1101 Wootton Parkway
Suite: 100
Rockville, MD 20852

NOAA
Corps

Phone: 301-713-3444

301-713-4140

[email protected]

U.S. Dept. of Commerce
NOAA/OMAO/CPC
8403 Colesville Rd, Suite 500, 5th Floor
Silver Spring, MD 20910

GL.2005.161(2) Ed. 02/2022

720-847-3887

*8732601*

SGLV 8600

GENERAL INFORMATION
The Servicemembers’ Group Life Insurance Traumatic Injury Protection (TSGLI) program provides for payment to service members who are
severely injured (on or off duty) as the result of a traumatic event and suffer a loss that qualifies for payment under TSGLI. TSGLI is designed to
help traumatically injured service members and their families with financial burdens associated with recovering from a severe injury. TSGLI
payments range from $25,000 to $100,000, based on the qualifying loss suffered.
WHO IS ELIGIBLE?
Effective December 1, 2005, all service members who are insured under SGLI and:
■

experience a traumatic event

■

that results in a traumatic injury

■

which is listed as a qualifying loss

are eligible to receive a TSGLI payment. Service members who were severely injured between October 7, 2001 and November 30, 2005 may
also be eligible for a TSGLI payment, regardless of where their injury occurred or whether they had SGLI coverage at the time of their injury.
Members should contact their branch of service for more information.
What is a Traumatic Event?
A traumatic event is the application of external force, violence, chemical, biological, or radiological weapons, accidental ingestion of a
contaminated substance, or exposure to the elements that causes damage to your body.
What is a Traumatic Injury?
A traumatic injury is the physical damage to your body that results from a traumatic event.
What is a Qualifying Loss?
A qualifying loss is a traumatic injury that is listed on the TSGLI Schedule of Losses, which lists all covered losses and payment amounts. You may
view the complete Schedule of Losses and other TSGLI information at http://www.benefits.va.gov/insurance/tsgli_schedule_Schedule.asp. Your
branch of service TSGLI office will determine whether your injury is a qualifying loss for TSGLI purposes.
HOW TO FILE A TSGLI CLAIM
Filing a TSGLI claim is a three-step process in which the service member [or guardian, power of attorney or military trustee] and a medical
professional must complete and submit the appropriate parts of the TSGLI Claim Form as follows:
Step 1

Step 2

Step 3

The service member [or guardian, power of
attorney or military trustee]…

The medical professional…

The medical professional OR the service member [or
guardian, power of attorney or military trustee]…

must complete Part A (pages 3 through 7) of the
form and give it to a medical professional to
complete Part B. Note: If a guardian or power
of attorney completes Part A, they must include
copies of letters of guardianship, letters of
conservatorship, power of attorney, or durable
power of attorney (if appropriate).

must complete Part B.

must forward Parts A and B, along with medical
records that document the member’s injury and
resulting loss, to the member’s branch of service
TSGLI office listed on the front cover of this form.

COMPLETING THE FORM
Instructions on completing the TSGLI Claim Form are included in each section. When completing the form, the service member, guardian, power
of attorney or military trustee must complete the service member’s Social Security number on each page of the form. If you have questions about
completing the form or if the member is deceased, please contact the branch of service TSGLI office listed on the front cover of this form.
CLAIM DECISION AND PAYMENT
Who Makes the Decision on My Claim?
Your branch of service TSGLI office will make the decision on your claim based upon the information in Parts A and B of the TSGLI Claim Form and
any supporting medical documentation you provide. They will then forward their decision to the Office of Servicemembers’ Group Life Insurance
(OSGLI) for appropriate action.

GL.2005.161(2) Ed. 02/2022

*8732602*
*

SGLV 8600 Page 1

Who Will Receive the TSGLI Payment?
Payment will be made directly to the member. If the member is unable, payment will be made under the appropriate letters of guardianship/
conservatorship or a power of attorney to the guardian, power of attorney or military trustee on the member’s behalf. If the member dies after
qualifying for payment, the payment will be made to the member’s current listed SGLI beneficiary(ies). The member must survive for seven days
(168 hours) from the date of the traumatic event to be eligible for TSGLI.
How the TSGLI Payment Will Be Made?
If your branch of service TSGLI office approves your claim, OSGLI will make the TSGLI benefit payment. There are three payment methods used
for TSGLI benefits: Prudential’s Alliance Account®,* Electronic Funds Transfer (EFT), or check. If you do not choose a payment option, OSGLI
will make the payment through Prudential’s Alliance Account.
1. Prudential’s Alliance Account*
1) The funds in an Alliance Account begin earning interest immediately and will continue to earn interest until all funds are withdrawn.
Interest is accrued daily, compounded daily and credited every month. The interest rate may change and will vary over time, subject
to a minimum rate that will not change more than once every 90 days. You will be advised in advance of any change to the minimum
interest rate via your quarterly Alliance Account statement or by calling Customer Support at (877) 255-4262.
2) The interest rate credited to the Alliance Account is adjusted by Prudential at its discretion based on variable economic factors
(including, but not limited to, prevailing market rates for short-term demand deposit accounts, bank money market rates and Federal
Reserve Interest rates) and may be more or less than the rate Prudential earns on the funds in the account.
3) An Alliance Account is an interest bearing draft account established in the beneficiary’s name with a draft book. The beneficiary can
write drafts for any amount up to the full amount of the proceeds. There are no monthly service fees or per draft charges and additional
drafts can be ordered at no cost, but fees apply for some special services including returned drafts, stop payment orders and copies
of statements/drafts.
4) The funds in your Alliance Account are available immediately. Use the drafts to access the account anytime you wish. You can write a
draft to yourself (which you can cash or deposit at your own bank) or write a draft to another person, or to any business as you need
your funds.
5) Alliance Account funds are part of Prudential’s General Account and are backed by the financial strength of The Prudential Insurance
Company of America which has been in business and serving its customers for over 140 years. The Alliance Account is not a bank
account or a bank product, and therefore, is not FDIC insured.
6) Account holders cannot make deposits into an Alliance Account. Only eligible payments from other Prudential insurance policies or
contracts may be added to the Alliance Account.
Note: A service member’s legal guardian, military trustee, or power of attorney (POA) may choose the Alliance Account payment option as
long as they submit proof of that appointment (i.e., the appropriate documentation) with the claim. The guardian, military trustee, or POA will
not have their name added to the account, but will be able to sign Alliance Account drafts on behalf of the member.
2. E lectronic Funds Transfer (EFT) — Your bank account will be electronically credited with the TSGLI payment amount. Depending
on your bank, payments will be credited three to five days from the date the payment is authorized.
3. Check Payment — A check will be issued to the service member, guardian, power of attorney or military trustee on behalf of the member.

* T he Bank of New York Mellon is the Administrator of the Prudential Alliance Account Settlement Option, a contractual obligation of The Prudential
Insurance Company of America, located at 751 Broad Street, Newark, NJ 07102-3777. Draft clearing and processing support is provided by The
Bank of New York Mellon. Alliance Account balances are not insured by the Federal Deposit Insurance Corporation (FDIC). The Bank of New
York Mellon is not a Prudential Financial company.

GL.2005.161(2) Ed. 02/2022

*8732603*

SGLV 8600 Page 2

PART A - Member’s Claim Information and Authorization - to be completed by the member, guardian, power of attorney or military trustee.
Service member’s Social Security number

1 Service member
Information

Service member’s First Name

The service member,
Date of Birth (mm/dd/yyyy)
guardian, power of
attorney or military
trustee MUST fill
in member’s Social
Branch of Service at time of injury
Security number at the
PHS
Army
top of each page.
Navy
Air Force

Service member’s Last Name

Marital Status
Married

Gender
Male
Female

Divorced

Single

Widowed

Rank/Grade
Marines
NOAA

Coast Guard
Space Force

Important Note:
Address of Record (number and street)
Contact information
must be completed.
Incomplete information City
will delay payment of
your claim.

Apt. (if any)

State

Telephone Number

ZIP Code

Email Address

Unit (at time of injury)

Third Party
Authorization

(Optional) I authorize the following person to speak with OSGLI or the Branch of Service about my
claim (this can be a spouse, parent, friend or another person who is helping you with your claim).

First Name

2 Guardian,

Power of
Attorney or
Military Trustee
Information
Important Note:
Please include
copies of the letters
of guardianship,
conservatorship, or
Power of Attorney,
etc. with this form.
Failure to include
this documentation
will delay processing
of the claim.

3 Traumatic

Injury
Information

Last Name

Complete this section ONLY if a guardian, power of attorney or military trustee will receive payment on behalf of the member.
First Name MI

Last Name

Mailing Address (number and street)

Apartment (if any)

City

State

ZIP Code

Telephone Number

Fax Number

Injuries that Qualify for TSGLI Payment
To qualify for the TSGLI benefit, you must have experienced a traumatic event that resulted in a traumatic injury that is
listed as a qualifying loss on the TSGLI Schedule of Losses.
Definitions:
Traumatic Event — A traumatic event is the application of external force, violence, chemical, biological, or radiological
weapons, accidental ingestion of a contaminated substance, or exposure to the elements that causes damage to your body.
Traumatic Injury — A traumatic injury is the physical damage to your body that resulted from a traumatic event (illness or
disease is not covered).
Qualifying Loss — A qualifying loss is a traumatic injury that is listed on the TSGLI Schedule of Losses. See the complete
Schedule of Losses at http://www.benefits.va.gov/insurance/tsgli_schedule_Schedule.asp.

GL.2005.161(2) Ed. 02/2022

*8732604*
*

SGLV 8600 Page 3

PART A - Member’s Claim Information and Authorization (cont’d) - to be completed by the member, guardian, power of attorney or military trustee.
Service member’s Social Security number

3 Traumatic

Injury
Information

Information About Your Loss
Is the loss you are claiming the result of any of the following:
a. an intentionally self-inflicted injury or an attempt to inflict such injury?

Yes No

b. use of an illegal or controlled substance that was not administered
or consumed on the advice of a medical doctor?

Yes No

c. the medical or surgical treatment of an illness or disease?

Yes No

d. a traumatic injury sustained while committing or attempting to commit a felony?

Yes No

e. a physical or mental illness or disease (not including illness or disease caused
by a wound infection, a chemical, biological, or radiological weapon, or the accidental
ingestion of a contaminated substance)?

Yes No

If you answered yes…
to any of the questions above, you are not eligible for a TSGLI payment and should not file a claim.
If you are not sure…
whether your loss is a result of one of the items above, please contact your Branch of Service TSGLI Office to find out
if you are eligible.
Tell us about your traumatic Injury
1. Were you covered under Servicemembers’ Group Life Insurance (SGLI) at the time of the injury?

Yes

2. In the box below, please describe your injury and give the date, time and location where it occurred. You must also submit
medical records with this claim that document your injuries and resulting loss. (See Part B for qualifying losses.)
Traumatic Injury Information

GL.2005.161(2) Ed. 02/2022

*8732604*
*

SGLV 8600

Page 4

PART A - Member’s Claim Information and Authorization (cont’d) - to be completed by the member, guardian, power of attorney or military trustee.
Service member’s Social Security number

41 Payment
Options

Please choose one of the three payment options below:

Payment Option 1 - Prudential’s Alliance Account

Please choose one
Complete the mailing address below (street address only, no P.O. boxes).
of the three payment
Service member’s Mailing Address for Payment - No P.O. Boxes
Apartment, Ward or Room (if any)
options by checking
the appropriate box
and filling in the
requested information.
City
State
ZIP Code
Payment Option 1
– Prudential’s
Alliance Account
An interest-bearing
Payment Option 2 - Electronic Funds Transfer (EFT)
account will be
To have the payment made by EFT, fill in your banking information below.
established in the
name of the member, Bank Routing Number
Bank Account Number
who can access the
Checking
money using the draft
Savings
book. A guardian,
Bank Phone Number
power of attorney, or Bank Name
military trustee may
sign Alliance Account
drafts on behalf of
First Name
MI
Last Name
the member if proof
of appointment is
submitted with
the claim.
Payment Option 2
– Electronic
Funds Transfer
This option can be
selected by member
or, if applicable, the
guardian, power of
attorney or military
trustee. Payment
will be made to the
service member’s
bank account.
Payment Option 3 –
Check
A check will be
issued to the service
member, guardian,
power of attorney
or military trustee on
behalf of the service
member.

Customer XYZ
XYZ Street
City, State, ZIP

The bank routing
number is always
9 digits and
appears between
the symbols

Check No. 1246

Check
Sample

PAY TO THE
ORDER OF

Dollars
Bank XYZ
UXYZ Street
City, State, ZIP
A27202754

Bank Routing Number

006666D66666C

1246

Bank Account Number

Check Number (not needed)

Payment Option 3 - Check
Important: If you are a guardian, power of attorney or military trustee you must complete the information below
when requesting a check.
Apartment (if any)

Mailing Address for Payment - No P.O. Boxes

City

5 Financial

Counseling
VA sponsors
financial counseling
for TSGLI recipients.

The bank account
number varies in
length and may
contain dashes or
spaces. The
symbol indicates
the end of the
account number.

State

ZIP Code

To receive this counseling, check the box below.
I would like to receive financial counseling with my TSGLI benefit.
You should get financial counseling as soon as possible after receiving your insurance money and before making any major financial decisions.
For more information on this benefit, visit http://www.benefits.va.gov/insurance/bfcs.asp.

GL.2005.161(2) Ed. 02/2022

*8732606*
*

SGLV 8600

Page 5

PART A - Member’s Claim Information and Authorization (cont’d) - to be completed by the member, guardian, power of attorney or military trustee.
Service member’s Social Security number

6 Signature

X
Signature of service member, guardian, power of attorney or military trustee Date Signed (mm/dd/yyyy) Description of Authority to
act on behalf of the member
WARNING: Any intentional false statement in this claim or willful misrepresentation relative thereto is subject to
(Guardian, POA, etc.)
punishment by a fine of not more than $10,000 or imprisonment of not more than five years, or both. (18 U.S.C. 1001)

Description of Authority: If the guardian, power of attorney or military trustee completes this section, they must also indicate their authority to act on behalf
of the member (e.g., guardian, conservator, etc.).

Member must complete and sign the HIPAA release on page 7

GL.2005.161(2) Ed. 02/2022

*8732607*
*

SGLV 8600

Page 6

PART A - Member’s Claim Information and Authorization (cont’d) - to be completed by the member, guardian, power of attorney or military trustee.
Service member’s Social Security number

Authorization
for Release of
Information to
Branch of Service
and Office of
Servicemembers’
Group Life
Insurance
The member,
guardian, power
of attorney, or
military trustee
must complete and
sign this section.
Failure to
complete this
section will
delay payment
of claim.
This Authorization
is intended to
comply with the
HIPAA Privacy Rule.

Member must complete and sign the HIPAA release below:
I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, medical
examiner or other health care provider that has provided treatment, payment or services pertaining to:
First Name

Last Name

Date of Birth (mm/dd/yyyy)

or on my behalf (“My Providers”) to disclose my entire medical record for me or my dependents and any other health information
concerning me to the Branch of Service and Office of Servicemembers’ Group Life Insurance (OSGLI) and its agents, employees,
and representatives. This also includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs,
and tobacco, but excludes psychotherapy notes. OSGLI is an administrative unit created by Prudential to administer the Servicemembers’
Group Life Insurance Program. OSGLI administers the TSGLI program on behalf of the Department of Veterans Affairs.
I authorize all non-health organizations, any insurance company, employer, or other person or institutions to provide any
information, data or records relating to credit, financial, earnings, travel, activities or employment history to OSGLI.
Unless limits* are shown below, this form pertains to all of the records listed above.
By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply to
this Authorization and I instruct My Providers to release and disclose my entire medical record without restriction.
This information is to be disclosed under this Authorization so that my Branch of Service and OSGLI may: 1) administer claims
and determine or fulfill responsibility for coverage and provision of benefits, 2) administer coverage, and 3) conduct other legally
permissible activities that relate to any coverage I have applied for with OSGLI.
This Authorization shall remain in force for 24 months following the date of my signature below, while the coverage is in force,
except to the extent that state law imposes a shorter duration. A copy of this Authorization is as valid as the original. I understand
that I have the right to revoke this Authorization in writing, at any time, by sending a written request for revocation to OSGLI at:
80 Livingston Avenue, Roseland, NJ 07068. I understand that a revocation is not effective to the extent that any of My Providers
has relied on this Authorization or to the extent that OSGLI has a legal right to contest a claim under an insurance policy or to
contest the policy itself. I understand that any information that is disclosed pursuant to this Authorization may be redisclosed and
no longer covered by federal rules governing privacy and confidentiality of health information.
I understand that if I refuse to sign this Authorization to release my complete medical record, OSGLI may not be able to process
my claim for benefits and may not be able to make any benefit payments. I understand that I have the right to request and receive
a copy of this Authorization.
*Limits, if any:
NOTE: This release authorizes the branch of service and OSGLI to look at medical records. You may also be asked to provide these documents.

Signature
The member, guardian,
power of attorney or
military trustee must
sign here.

X
Signature of service member, guardian, power of attorney or military trustee
Date Signed (mm/dd/yyyy)

GL.2005.161(2) Ed. 02/2022

*8732608*
*

Description of Authority to
act on behalf of the member
(Guardian, POA, etc.)

SGLV 8600

Page 7

PART B - Medical Professional’s Statement - to be completed by a medical professional who is a licensed practitioner of the healing arts
acting within the scope of his/her practice.
Service member’s Social Security number

Patient
Information

Patient’s First Name

Patient’s Last Name

Date of Injury (mm/dd/yyyy)

If patient is deceased, please provide:
Time of Death

Date of Death (mm/dd/yyyy)

a.m.
p.m.

Cause of Death

Qualifying
Losses Suffered
by Patient

Inpatient hospitalization is defined as: “Being hospitalized as an inpatient for 15 consecutive days as the result of a traumatic injury”

Instructions:
Please check the
box next to each
loss the patient has
experienced and fill
in any additional
information
requested. Omitted
information, such
as sight or hearing
measurements, will
delay processing of
the claim.

Hospital does not include a nursing home. Neither does it include an institution, or part of one, which: (1) is used mainly as a place for
convalescence, rest, nursing care or for the aged; or (2) furnishes mainly homelike or Custodial Care, or training in the routines of daily living;
or (3) is for residential or domiciliary living; or (4) is mainly a school.

Patient’s loss MUST
meet the definition
of loss given.

Definition of a hospital – A hospital that is accredited as a hospital under the Hospital Accreditation Program of the Joint Commission on
Accreditation of Healthcare Organizations. This includes Combat Support Hospitals, Air Force Theater Hospitals and Navy Hospital Ships.

Was the member hospitalized as an inpatient for at least 15 consecutive days?

Yes

Reason for Inpatient Hospitalization – Please give the predominant reason the patient was hospitalized.
Traumatic Brain Injury

Other Traumatic Injury

Longest Period of Inpatient Hospitalization – Please give the beginning and ending dates for the longest period of consecutive days the
patient was hospitalized as an inpatient. The count of consecutive inpatient hospitalization days begins when the injured member is transported
to the hospital (if applicable), includes the day of admission, continues through subsequent transfers from one hospital to another, and includes
the day of discharge.
Date of transport (mm/dd/yyyy)

Date of discharge (mm/dd/yyyy)

Date of Admission (mm/dd/yyyy)

OR C heck here
if still
hospitalized

Name and location of hospital (if more than one hospital, list all)

Loss of Sight
Loss of sight in left eye or
anatomical loss of left eye

Loss of Sight is defined as:
■

■

Visual acuity in at least one eye of 20/200 or
less (worse) with corrective lenses, OR

Date of onset/loss (mm/dd/yyyy)

Loss of sight in right eye or
anatomical loss of right eye

Visual acuity in at least one eye of greater (better)
than 20/200 with corrective lenses and a visual
field of 20 degrees or less, OR
Anatomical loss of eye. Loss of sight must be expected
to be permanent OR must have lasted at least 120 days.

Visual Acuity and Field

Left Eye

Right Eye

Best corrected visual acuity
Visual Field (degrees)
Loss of Speech

Loss of Speech is defined as:

GL.2005.161(2) Ed. 02/2022

*8732609*
*

Date of onset (mm/dd/yyyy)

Loss of speech

An organic loss of speech (lost the ability to express oneself,
both by voice and by whisper, through normal organs for
speech). If a member uses an artificial appliance, such as a
voice box, to simulate speech, he/she is still considered to
have suffered an organic loss of speech and is eligible for a
TSGLI benefit.

SGLV 8600

Page 8

PART B - Medical Professional’s Statement (cont’d) - to be completed by a medical professional who is a licensed practitioner of the
healing arts acting within the scope of his/her practice.
Service member’s Social Security number

Qualifying
Losses
Suffered by
Patient (cont’d)

Loss of Hearing

Loss of hearing is defined as:
Average hearing threshold sensitivity for air conduction of
at least 80 decibels. Hearing Acuity must be measured at
500 Hz, 1000 Hz and 2000 Hz to calculate the average hearing
threshold. Loss of hearing must be clinically stable and
unlikely to improve.

Date of onset (mm/dd/yyyy)

Loss of hearing in left ear
Loss of hearing in right ear
Hearing Acuity
Average Hearing Acuity (measured
without amplification device)

Burns are defined as:

Left Ear

Right Ear

Burns

2nd degree (partial thickness) or worse burns over 20% of the
body including the face and head OR 20% of the face only.

2nd degree or worse burns to the body including face and head
2nd degree or worse burns to the face only

Note: Percentage may be measured using
the Rule of Nines or any other acceptable alternative.

Percentage of
body affected

Coma is defined as:

Percentage of
face affected

Coma

Coma with brain injury measured at a Glasgow Coma Score
of 8 or less that lasts for 15, 30, 60 or 90 consecutive days.

Coma
Date of onset (mm/dd/yyyy)

Number of days includes the date the coma began and the
date the member recovered from the coma.

Date of recovery (mm/dd/yyyy)

OR Check here if coma is ongoing
Glasgow score at 15 days

Glasgow score at 30 days

Important:

Facial Reconstruction is defined as:

Facial
Reconstruction:
If the patient is
undergoing facial
reconstruction, a
surgeon MUST
certify this section
by checking the box,
printing his/her name
and signing on the
appropriate line.

Reconstructive surgery to correct traumatic avulsions of the
face or jaw that cause discontinuity defects, specifically
surgery to correct discontinuity loss of the following:

Glasgow score at 60 days

Glasgow score at 90 days

Facial Reconstruction
Upper or lower jaw

50% of left zygomatic

50% of cartilaginous nose

50% of right zygomatic

50% of upper lip

50% of left mandibular

■

upper or lower jaw

■

50% or more of the cartilaginous nose

■

50% or more of the upper or lower lip

50% of lower lip

50% of right mandibular

■

30% or more of the periorbital

30% of left periorbital

50% of left infraorbital

t issue in 50% or more of any of the following facial
subunits: forehead, temple, zygomatic, mandibular,
infraorbital or chin

30% of right periorbital

50% of right infraorbital

50% of left temple

50% of chin

50% of right temple

50% of forehead

■

Certification of Surgeon
Date of first surgery (mm/dd/yyyy)

First Name of Surgeon

Last Name of Surgeon

Specialty

Date Signed (mm/dd/yyyy)

X
Signature of Surgeon
Telephone Number

GL.2005.161(2) Ed. 02/2022

*8732610*
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SGLV 8600

Page 9

Qualifying
Losses
Suffered by
Patient (cont’d)

Amputation is: the severance or removal of a limb or genital organ or part of a limb or genital organ, including both severance due to a
traumatic injury, or surgical removal that is required for the treatment of a traumatic injury.
Amputation of Hand

Amputation of Hand is defined as:
Amputation of hand at or above the wrist.

Date of amputation (mm/dd/yyyy)

Amputation of left hand

Above the wrist means closer to the body.
Amputation of right hand
Amputation of Fingers

Amputation of Fingers is defined as:
■

■

Amputation of 4 fingers/
right hand

Amputation of thumb at or above
the metacarpophalangeal joint.

Amputation of left thumb

Above the metacarpophalangeal joint
means closer to the body.

Amputation of right thumb
Amputation of Foot

Amputation of Foot is defined as:
■
■

Amputation of foot at or above the ankle, OR

Amputation of right foot

Amputation of Toes

Amputation of Toes is defined as:
Amputation of four toes on
one foot at or above the
metatarsophalangeal joint
(not including the big toe),

Amputation of 4 toes/
left foot

Amputation of big toe at or above
the metatarsophalangeal joint.

Amputation of big toe/
left foot
Amputation of big toe/
right foot

Above the metatarsophalangeal joint
means closer to the body.

Important:
Limb Salvage:
If the patient is
undergoing limb
salvage, a surgeon
MUST certify this
section by printing
his/her name and
signing on the
appropriate line.

Date of amputation (mm/dd/yyyy)

Amputation of 4 toes/
right foot

OR
■

Date of amputation (mm/dd/yyyy)

Amputation of left foot

Amputation of all toes (including the big toe) on the
same foot at or above the metatarsophalangeal joint.

Above the ankle and above the metatarsophalangeal joint
means closer to the body.

■

Date of amputation (mm/dd/yyyy)

Amputation of 4 fingers/
left hand

Amputation of four fingers on
the same hand (not including the
thumb) at or above the
metacarpophalangeal joint, OR

Limb Salvage

Limb Salvage is defined as:
A series of operations designed to avoid amputation of an
arm or a leg while at the same time maximizing the limb’s
functionality. The surgeries typically involve bone and skin
grafts, bone resection, reconstructive, and plastic surgeries
and often occur over a period of months or years.

Salvage of left arm

Submit operative report for each surgery.

Salvage of right arm

Salvage of left leg

Salvage of right leg

Certification of Surgeon
I certify that the patient is undergoing limb salvage surgery as defined
in the column to the right.
First Name of Surgeon

Date of first surgery (mm/dd/yyyy)

Additional Comments

Last Name of Surgeon

Specialty

Telephone Number

Date Signed (mm/dd/yyyy)

X
Signature of Surgeon

GL.2005.161(2) Ed. 02/2022

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Page 10

Qualifying
Losses
Suffered by
Patient (cont’d)

Paralysis is defined as:

Paralysis

Complete paralysis due to damage to the spinal cord or
associated nerves, or to the brain. A limb is defined as an
arm or a leg with all its parts. Paralysis must fall into one
of the four categories listed below:

Date of onset (mm/dd/yyyy)

Quadriplegia
Paraplegia

■

Quadriplegia - paralysis of all four limbs

■

Paraplegia - paralysis of both lower limbs

Hemiplegia

Hemiplegia - paralysis of the upper and lower limbs on
one side of the body

Uniplegia

■

Uniplegia - paralysis of one limb

Anatomical loss of the penis is defined as:

Genitourinary System Losses

Amputation of the glans penis or any portion of the shaft of
the penis above the glans penis or damage to the glans penis
or shaft of the penis that requires reconstructive surgery.

Anatomical loss
of the penis

Date of loss or amputation (mm/dd/yyyy)

Permanent loss of
use of the penis

Date of loss (mm/dd/yyyy)

Anatomical loss of
one testicle

Date of loss or amputation (mm/dd/yyyy)

Anatomical loss of
both testicles

Date of loss or amputation (mm/dd/yyyy)

Permanent loss of
use of both testicles

Date of loss (mm/dd/yyyy)

Anatomical loss of
the vulva

Date of loss or amputation (mm/dd/yyyy)

Anatomical loss of
the uterus

Date of loss or amputation (mm/dd/yyyy)

Anatomical loss of
the vaginal canal

Date of loss or amputation (mm/dd/yyyy)

Permanent loss of
use of the vulva

Date of loss (mm/dd/yyyy)

Permanent loss of use
of the vaginal canal

Date of loss (mm/dd/yyyy)

Above the glans penis means closer to the body.
Permanent loss of use of the penis is defined as:
Damage to the glans penis or shaft of the penis that results
in complete loss of the ability to perform sexual intercourse
that is reasonably certain to continue throughout the lifetime
of the member.
Anatomical loss of one testicle is defined as:
The amputation of, or damage to, one testicle that requires
testicular salvage, reconstructive surgery, or both.
Anatomical loss of both testicle(s) is defined as:
The amputation of, or damage to, both testicles that requires
testicular salvage, reconstructive surgery, or both.
Permanent loss of use of both testicles is defined as:
Damage to both testicles resulting in the need for hormonal
replacement therapy that is medically required and reasonably
certain to continue throughout the lifetime of the member.
Anatomical loss of the vulva is defined as:
The complete or partial amputation of the vulva or damage
to the vulva that requires reconstructive surgery.
Anatomical loss of the uterus is defined as:
The complete or partial amputation of the uterus or damage
to the uterus that requires reconstructive surgery.
Anatomical loss of the vaginal canal is defined as:
The complete or partial amputation of the vaginal
canal or damage to the vaginal canal that requires
reconstructive surgery.
Permanent loss of use of the vulva is defined as:
Damage to the vulva that results in complete loss of the
ability to perform sexual intercourse that is reasonably
certain to continue throughout the lifetime of the member.
Permanent loss of use of the vaginal canal is defined as:
Damage to the vaginal canal that results in complete loss of
the ability to perform sexual intercourse that is reasonably
certain to continue throughout the lifetime of the member.

GL.2005.161(2) Ed. 02/2022

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Qualifying
Losses
Suffered by
Patient (cont’d)

Anatomical loss of the ovary is defined as:
The amputation of one ovary or damage to one ovary that
requires ovarian salvage, reconstructive surgery, or both.
Anatomical loss of both ovaries is defined as:
The amputation of both ovaries or damage to both ovaries that
requires ovarian salvage, reconstructive surgery, or both.
Permanent loss of use of both ovaries is defined as:
Damage to both ovaries resulting in the need for hormonal
replacement therapy that is medically required and reasonably
certain to continue throughout the lifetime of the member.
Total and permanent loss of urinary system function
is defined as:

Anatomical loss of
one ovary

Date of loss or amputation (mm/dd/yyyy)

Anatomical loss of
both ovaries

Date of loss or amputation (mm/dd/yyyy)

Permanent loss of
use of both ovaries

Date of loss (mm/dd/yyyy)

Total and permanent loss of
urinary system function

Date of loss (mm/dd/yyyy)

Damage to the urethra, ureter(s), both kidneys, bladder, or
urethral sphincter muscle(s) that requires urinary diversion
and/or hemodialysis, either of which is reasonably certain to
continue throughout the lifetime of the member.
Description
of Injury/
Assistance Needed
Please provide a
description of the
injury and
descriptions of the
assistance needed to
perform each ADL.
Failure to provide this
information may delay
processing of claim.

Inability to Independently Perform Activities of Daily Living (ADL)
Inability to Independently Perform ADL is defined as:
Inability to independently perform at least two of six ADL (bathing, continence, dressing, eating, toileting and transferring). Inability must last
for at least 15 consecutive days for traumatic brain injury and at least 30 consecutive days for any other traumatic injury.
The patient is considered unable to perform an activity independently only if he or she REQUIRES assistance to perform the activity. If the
patient is able to perform the activity by using accommodating equipment, such as a cane, walker, commode, etc., the patient is considered
able to independently perform the activity without requiring assistance.
Requires Assistance is defined as:
■ physical assistance (hands-on),
■ standby assistance (within arm’s reach),
■ verbal assistance (must be instructed because of cognitive impairment),
without which the patient would be INCAPABLE of performing the task.

What is the
predominant reason
the patient is/was
What is the predominant reason the patient is/was unable to independently perform ADL?
unable to
Traumatic Brain Injury
Other Traumatic Injury
independently
(Please describe injury and give reason(s) it resulted in inability to perform activities of daily living.)
perform ADL?
Check the
predominant reason
the patient cannot
independently
perform ADL and
describe the injury in
the box provided.

GL.2005.161(2) Ed. 02/2022

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Page 12

Qualifying
Losses
Suffered by
Patient (cont’d)
Which ADL is the
patient unable to
perform?
Check each ADL
the patient cannot
perform;
AND
Fill in the dates
inability began and
ended or indicate
inability is ongoing.

Require
Assistance
is defined as:
■ physical
assistance
(hands-on),
■ standby
assistance (within
arm’s reach),
■ verbal assistance
(must be
instructed
because of
cognitive
impairment),
without which
the patient would
be INCAPABLE
of performing
the task.

Inability to Independently Perform Activities of Daily Living (ADL) (cont’d)
Patient is UNABLE to bathe independently if…

Unable to bathe independently
Start date (mm/dd/yyyy)

He/she requires assistance from another person to bathe
(including sponge bath) more than one part of the body or get
in or out of the tub or shower.
Describe assistance needed:

End date (mm/dd/yyyy)

OR Check here if inability is ongoing
Type of assistance required (check all that apply)
physical assistance (hands-on)
standby assistance
(within arm’s reach)

Patient is UNABLE to maintain continence
independently if…

verbal assistance (must be
instructed because of
cognitive impairment)

Unable to maintain continence independently
Start date (mm/dd/yyyy)
End date (mm/dd/yyyy)

He/she is partially or totally unable to control bowel and
bladder function or requires assistance from another person
to manage catheter or colostomy bag.

OR Check here if inability is ongoing

Describe assistance needed:

Type of assistance required (check all that apply)
physical assistance (hands-on)
standby assistance
(within arm’s reach)

Patient is UNABLE to dress independently if…

Unable to dress independently
Start date (mm/dd/yyyy)

He/she requires assistance from another person to get and
put on clothing, socks or shoes.

verbal assistance (must be
instructed because of
cognitive impairment)

End date (mm/dd/yyyy)

Describe assistance needed:
OR Check here if inability is ongoing
Type of assistance required (check all that apply)
physical assistance (hands-on)
standby assistance
(within arm’s reach)
Patient is UNABLE to eat independently if…

Unable to eat independently
Start date (mm/dd/yyyy)

He/she requires assistance from another person to:
■

get food from plate to mouth, OR

■

take liquid nourishment from a straw or cup, OR

Describe assistance needed:

Type of assistance required (check all that apply)
physical assistance (hands-on)
standby assistance
(within arm’s reach)

*87326014*
*

End date (mm/dd/yyyy)

OR Check here if inability is ongoing

he/she is fed intravenously or by a feeding tube.

GL.2005.161(2) Ed. 02/2022

verbal assistance (must be
instructed because of
cognitive impairment)

SGLV 8600

Page 13

Qualifying
Losses
Suffered by
Patient (cont’d)

Inability to Independently Perform Activities of Daily Living (ADL) (cont’d)
Patient is UNABLE to toilet independently if…

Unable to toilet independently
Start date (mm/dd/yyyy)

He/she must use a bedpan or urinal to toilet, OR
he/she requires assistance from another person with any of
the following: going to and from the toilet, getting on and off
the toilet, cleaning self after toileting, getting clothing off
and on.

Describe assistance needed:

End date (mm/dd/yyyy)

Check here if inability is ongoing

Type of assistance required (check all that apply)
physical assistance (hands-on)
standby assistance
(within arm’s reach)

Patient is UNABLE to transfer independently if…

verbal assistance (must be
instructed because of
cognitive impairment)

Unable to transfer independently
Start date (mm/dd/yyyy)
End date (mm/dd/yyyy)

He/she requires assistance from another person to move into
or out of a bed or chair.
Describe assistance needed:

Check here if inability is ongoing

Type of assistance required (check all that apply)
physical assistance (hands-on)
standby assistance
(within arm’s reach)

Other
Information

verbal assistance (must be
instructed because of
cognitive impairment)

To your knowledge, were any of the losses indicated in Part B due to:
a. an intentionally self-inflicted injury or an attempt to inflict such injury,
b. use of an illegal or controlled substance that was not administered or consumed on the advice of a medical doctor,
c. the medical or surgical treatment of an illness or disease,
d. a physical or mental illness or disease (not including illness or disease caused by a pyogenic infection, a chemical, biological, or radiological
weapon, or the accidental ingestion of a contaminated substance).
If yes, please explain below:

Medical
Professional’s
Comments

Use this block to provide any additional information about the patient’s injuries. When a narrative description is required, please be
complete and concise.

GL.2005.161(2) Ed. 02/2022

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Page 14

Medical
Professional’s
Information

Name of Medical Professional
First Name

Last Name

Medical Professional’s Address (number and street)

Suite

City

State

ZIP Code

Telephone Number

Fax Number

Email Address

Specialty

Medical Degree

Medical Professional’s License number

Medical
Professional’s
Signature

I have been directly involved in the patient’s care for his/her loss.
I have not treated the patient for his/her loss but I have reviewed the patient’s medical records.
Do you feel the claimant is competent to endorse checks and direct the use of the proceeds?

Yes

This Medical Professional’s Statement is based upon my examination of the patient, and/or, a review of pertinent medical
evidence. I understand the patient and/or I may be asked to provide supporting documentation to validate eligibility under the law.
Date (mm/dd/yyyy)

Signature

WARNING: Any intentionally false statement in this claim or willful misrepresentation relative thereto is subject to punishment
by a fine of not more than $10,000 or imprisonment of not more than five years, or both. (18 U.S.C. 1001)

PRIVACY ACT NOTICE: 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 (i.e., use by VA employees and your authorized representatives in the maintenance of Government Insurance
programs) identified in the VA system of records, 36VA29, Veterans and Uniformed Services Personnel Programs of U. S. Government Life Insurance - VA, published in
the Federal Register. Your obligation to respond is voluntary, but your failure to provide us the information could impede processing. No insurance may be granted unless
a completed application form has been received (38 U.S.C. 2106 and 38 CFR 8a3(e)). Giving us your SSN account information is voluntary. Refusal to provide your SSN
by itself will not result in the denial of benefits . 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. The responses you submit are considered
confidential (38 U.S.C. 5701).
RESPONDENT BURDEN: We need this information to determine, establish or verify your eligibility for VA Insurance benefits. Title 38, United States Code, allows us to
ask for this information. We estimate that you will need an average of 15 minutes to review the instructions, find the information, and complete this form. VA cannot
conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this
number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call
1-800-827-1000 to get information on where to send comments or suggestions about this form.

GL.2005.161(2) Ed. 02/2022

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Page 15

File Type	application/pdf
File Title	Application for TSGLI Benefits
Author	Prudential
File Modified	2022-12-22
File Created	2022-02-18