SGLV 8600A TSGLI Appeal Request Form

OMB Control No. 2900-0919
Respondent Burden: 10 hours
Expiration Date: 7/31/2023

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

TSGLI Appeal Request Form
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, Option 1
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 Avenue
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 Joint Base San
Antonio - Randolph, 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
2700 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
Silver Spring, MD 20910

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SGLV 8600A

TSGLI APPEAL REQUEST FORM
Instructions
Use this form when filing an appeal for previously denied benefits under the Servicemembers’ Group Life Insurance Traumatic Injury
Protection (TSGLI) program. Requests must be submitted to your branch’s TSGLI office or Appeal office within one year of a claim’s denial
date. Please review your previous decision letter for instructions on where to submit your appeal and whether this form is required.
If you are submitting a new claim or claiming losses that were not previously reviewed, an Application for TSGLI Benefits (SGLV-8600)
needs to be completed.

Who Makes the Decision on My Appeal?
Your branch of service TSGLI office, or its higher appeal authority, will make the decision on your appeal based upon the information
provided on this form and any supporting documentation you provide. They will then forward their decision to the Office of
Servicemembers’ Group Life Insurance (OSGLI) for appropriate action.

1.

First Name

2.

SSN (Last 4 digits)

3.

Address: Street or PO Box

MI

Last Name

Date of Birth (mm dd yyyy)

City

State

4.

Phone Number

Email Address

5.

Date of traumatic event/injury (mm dd yyyy)

Location

6.

List losses from TSGLI Schedule of Losses that are being appealed.

ZIP Code

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

MI

Last Name

Guardian, Power of Attorney, or Military Trustee Information
Important Note: Please include copies of the letters of guardianship, conservatorship, Power of Attorney, or DD Form 2827 –
Application for Trusteeship etc. with this form. Failure to include this documentation will delay processing of your appeal.
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

Telephone Number

Fax Number

GL.2016.030 Ed. 04/2023

ZIP Code

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SGLV 8600A  Page 2 of 6

7. Reason for appeal: Please check the box(es) that explain the reason(s) for your appeal. After each selected reason please
provide a brief description of any new supporting evidence (Example: specific page number(s) in medical records, date(s)
of medical records, police report, supporting statements etc.).
NOTE: To avoid delays in the review process, please highlight any new and material evidence within medical records and
submit only the new evidence/documentation that supports the appeal. There is no need to resubmit all previously submitted
documents as they will be considered when your appeal is reviewed.
To support my appeal, I am providing new evidence or documentation to support: (check all that apply):
SGLI coverage was in effect at the time of the traumatic event.
Description of new evidence:
New medical evidence to support my loss.
Description of new evidence:
My loss occurred within 730 days of the traumatic event.
Description of new evidence:
My loss was not due to a physical or mental illness.
Description of new evidence:
My loss was the direct result of a traumatic event.
Description of new evidence:
My traumatic injury was not willfully caused by my own actions.
Description of new evidence:
I was not committing or attempting to commit a felony when my traumatic injury occurred.
Description of new evidence:
I did not willfully use an illegal or controlled substance leading up to my traumatic injury.
Description of new evidence:
My loss was not the result of a medical or surgical procedure.
Description of new evidence:
My loss was not the result of an attempted suicide.
Description of new evidence:
Other (reason is not listed above).
Description of new evidence:

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8. Please provide any additional supporting details to be considered when your appeal is reviewed.

Date Signed (mm dd yyyy)

X
Signature

GL.2016.030 Ed. 03/2023

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

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SGLV 8600A  Page 4 of 6

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 PO boxes).
of the three payment
Servicemember’s Mailing Address for Payment—No PO 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
Bank Routing Number
Bank Account Number
Servicemember,
Checking
who can access
Savings
the money using
Bank Name
Bank Phone Number
the draft book. A
guardian or power
of attorney may sign
Alliance Account®
First Name
MI
Last Name
drafts on behalf of
the Servicemember, if
proof of appointment
is submitted with the
claim.
Customer XYZ
Check No. 1246
XYZ Street
City, State, ZIP

Payment Option 2
– Electronic
Funds Transfer
This option can be
selected by the
Servicemember or,
if applicable, the
guardian, power of
attorney, or military
trustee. Payment
will be made to the
Servicemember’s
bank account, or
in the case of a
military trustee, the
trusteeship account.

Check
Sample

PAY TO THE
ORDER OF

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

$
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

Payment Option 3 –
when requesting a check.
Check
A check will be issued Mailing Address for Payment—No PO Boxes
to the Servicemember,
guardian, power of
attorney, or military
City
trustee on behalf of
the Servicemember.

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.

Apartment (if any)

State

ZIP Code

To receive this counseling, check the box below.
I would like to receive financial counseling with my TSGLI benefit. This counseling is offered at no cost to you.
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.

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

GL.2016.030 Ed. 04/2023

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

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

SGLV 8600A  Page 5 of 6

Authorization
for Release of
Information to
Branch of Service
and Office of
Servicemembers’
Group Life
Insurance
The Servicemember,
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

MI

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 Servicemember,
guardian, power of
attorney, or military
trustee must sign here.

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

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

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 10 hours 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.

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SGLV 8600A  Page 6 of 6