SGLV 8284 Claim for Accelerated Benefits Servicemembers’ Group Lif

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/20XX

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.
PRIVACY ACT INFORMATION: No insurance may be converted unless a completed application form has been received (38 U.S.C. 1904 and 1942). The 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 5, Code of Federal Regulations 1.526 for routine uses as identified in 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 required to obtain or retain benefits. The responses you submit are considered
confidential (38 USC 5701).
RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control Number. The OMB control
number for this project is 2900-0618, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 12 minutes per respondent, per year, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any
other aspect of this collection of information, including suggestions for reducing the burden to VA Reports Clearance Officer at [email protected]. Please refer to OMB Control No. 2900-0618 in any
correspondence. Do not send your completed VA Form SGLV 8284 to this email address.

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