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We understand you file claims during difficult times, (Little Rock School District)

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Transamerica Financial Life Insurance Company / Transamerica Life Insurance Company
Transamerica Claims PO Box 219 Cedar Rapids IA 52406–0219
We understand you file claims during difficult times, and Transamerica is committed to
helping you care for your health without sacrificing your financial future. We know this form
asks for a lot of information, but it’s all important for processing your claim smoothly. Follow
these steps to get started and avoid missing any pieces:
Submitting your claim online is a lot faster,
and it lets you track the status
anytime, anywhere. Visit www.tebcs.com to complete this form online instead.
When you submit your claim online,
sign up for
direct deposit
—
that’s the
fastest and safest way to receive any payments you are eligible for.
Sticking with paper? No problem. Just make sure you provide complete and
accurate information for each field — missing information can delay your claim.
And remember you can always scan your completed form and email it to us at
tebclaimsscanning@transamerica.com.
At least three forms are required
for everyone who submits a claim. These are all included
and clearly labeled in this document:
The
Claimant’s Statement
is the core document of your claim. It describes your
claim and captures critical information about you and your policy/certificate.
The
HIPAA Authorization Form
lets us access your personal health information
to determine how your policy/certificate covers your claim. Note that if you file a
claim for a dependent over age 18, the claimant (patient) needs to sign and date
this form themselves — you cannot sign it for them.
The
Physician’s Statement
is a document you give to the doctor who provided the
treatment related to your claim. Take a moment to verify the doctor answered all
the questions, including signing and dating the form.
Your claim may require additional documentation.
Go to the next page to see what you
need — we’ve tried to make it as easy as possible.
Questions?
VISIT: tebcs.com
EMAIL: tebcustresp@transamerica.com
CALL: 888-763-7474 (weekdays 7am – 5pm ET)
HOW TO FILE YOUR CLAIM
1
2
3
Transamerica Financial Life Insurance Company / Transamerica Life Insurance Company
Transamerica Claims PO Box 219 Cedar Rapids IA 52406–0219
FORMS INCLUDED IN THIS DOCUMENT
ACCIDENT
DISABILITY
CRITICAL
ILLNESS
CANCER
ICU
/
HOSPITAL
INDEMNITY
Claimant’s statement
●
●
●
●
●
HIPAA Authorization
●
●
●
●
●
Physician’s Statement
●
●
●
●
●
Medical History Form
●
●
Employer’s Statement
●
MATERIALS TO SUMBIT WITH YOUR CLAIM
Itemized statements of medical charges
●
●
●
Police report (motor vehicle accidents)
●
●
Discharge summary
●
●
●
First report of injury
●
Diagnostic report
●
Pathology report
●
●
Date of diagnosis
●
Medicare, Medicaid, insurance statements
●
Ambulance statement
●
●
Submit your claim online
or with this form
We’ll confirm
receipt once it’s
in our files
We review your
claim ASAP
We determine how
your policy covers
your claim
We send you
the details of
your benefits
SUBMISSION
CONFIRMATION
REVIEW
DECISION
EXPLANATION
WHAT HAPPENS AFTER YOU FILE A CLAIM?
INFORMATION YOU NEED TO FILE A CLAIM
Go to the next page and let’s get started!
Transamerica Financial Life Insurance Company / Transamerica Life Insurance Company
Transamerica Claims PO Box 219 Cedar Rapids IA 52406–0219
CLAIMANT’S STATEMENT
PAGE 1 OF 2
You must complete this Claimant’s Statement for any claim you file. This
information helps us determine how your policy/certificate covers your claim.
1. Primary insured’s full name
2. Date of birth
3. Policy/certificate number
4. Social Security number
5a. Mailing address
5b. Street address
8. Patient’s full name
6. Phone number
7. Email address
9. Date of birth
10. Relationship to insured
11. Nature of injury or illness
13. Date first treated or diagnosed
12. When did your symptoms first appear, or when did the accident occur? If this is related to an injury, explain fully
how, when, and where accident occurred.
ABOUT YOUR INJURY OR ILLNESS
For questions 11-15, complete the information that applies to your situation. If you need more space for any question, you can
use an additional sheet of paper and attach it to this form.
15. Do you have
Medicare?
Yes
No
Do you have
Medicaid?
Yes
No
Do you have other health insurance?
Yes — Company name:
No
CONTACT INFORMATION
What is the policy/certificate you’re filing this claim under? It can be more than one, so check all that apply:
☐ Accident ☐ Disability ☐ Critical Illness ☐ Cancer ☐ Heart/stroke ☐ Intensive Care / Hospital Indemnity
CLAIM TYPE
1
14. Were you hospital confined? Please include the hospital’s name, address, and phone.
Yes: from _______ to _______
No
Transamerica Financial Life Insurance Company / Transamerica Life Insurance Company
Transamerica Claims PO Box 219 Cedar Rapids IA 52406–0219
CLAIMANT’S STATEMENT
PAGE 2 OF 2
INCOME SOURCES
Answer question 15
only if you’re filing a
disability claim.
In that case, you also will need to have your employer
complete the Employer’s Statement, which is included with this document.
Don’t forget to sign and date this Claimant’s Statement below: we can’t evaluate
your claim without your signature!
Printed name
Claimant’s signature
Date (MM/DD/YYYY)
All the above answers and statements are true and complete and correctly recorded. I read and understand the
appropriate Fraud Warning. I understand that the furnishings of forms by the company does not constitute an
admission that there is any insurance coverage in force or payable.
For residents of New York: any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance or statement of claim containing any materially false information, or conceals
for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act,
which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of
the claim for each such violation. The Internal Revenue Service does not require your consent to any provision of this
document other than the certifications required to avoid backup withholding.
Short-term disability
Worker’s compensation
Social Security
Dependent Social Security
No Fault (income replacement)
Retirement / Pension
Permanent Total Disability
Other (identify below)
APPLIED
☐
☐
☐
☐
☐
☐
☐
☐
RECEIVING
☐
☐
☐
☐
☐
☐
☐
☐
AMOUNT
$_________
$_________
$_________
$_________
$_________
$_________
$_________
$_________
FREQUENCY
______________
______________
______________
______________
______________
______________
______________
______________
DATES
___________ to ____________
___________ to ____________
___________ to ____________
___________ to ____________
___________ to ____________
___________ to ____________
___________ to ____________
___________ to ____________
15. To the best of your knowledge, indicate if you have filed for, or are receiving income from, any of the following sources:
Salary continuance or sick leave ☐ Yes ☐ No If yes, how many hours since you last worked? __________
Extended illness benefit or time off ☐ Yes ☐ No If yes, how many hours since you last worked? __________
1
Transamerica Financial Life Insurance Company / Transamerica Life Insurance Company
Transamerica Claims PO Box 219 Cedar Rapids IA 52406–0219
This authorization complies with the HIPAA Privacy Rule, and it’s
required for all claims. A copy of this authorization will be considered
as valid as the original.
Note to claimant/personal representative:
This authorization must be signed for us to receive medical
records under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). Although we may
not need to obtain medical records to process your claim, we must obtain this form to avoid possible delays
if medical information is needed.
I authorize all physicians, medical practitioners, hospitals, clinics, pharmacies, pharmacy benefit managers,
long term care facilities (including assisted living facilities), home health care entities and other medical care
institutions, medically related facilities, medical or hospital service and prepaid health plans, employers and
group policy holders, contract holders and benefit plan administrators, state and federal governmental
agencies (including law enforcement agencies), Social Security Administration, Internal Revenue Service and
Veteran Administration facilities, coroners, medical examiners and any other person or entity that has any
health information relating to the insured/patient named below (collectively, the “Providers”) to disclose the
entire medical record
and any other protected health information concerning the insured/patient to the
Transamerica Financial Life Insurance Company and/or Transamerica Life Insurance Company (the
“Companies”), their affiliates and reinsurers, and any business associate, agent, employee, representative,
investigator, benefit plan administrator, consumer reporting agency (including MIB, Inc. formerly known as
the Medical Information Bureau) or independent claim administrator acting on behalf of any of the
Companies (the “Permitted Recipients”). This authorization includes release of any oral, written, or
electronic information, records, documents, or knowledge concerning any medical care, medical advice,
diagnosis, treatment or supplies, including psychiatric or mental health records (excluding psychotherapy
notes), prescription drug information, substance abuse records, medical records, medical notes, and medical
recordings. This authorization also consents to disclosure of information on the diagnosis or treatment of
Human Immunodeficiency Virus (HIV) infection, AIDS and sexually transmitted diseases, to the extent
permitted by state law.
By my signature below, I acknowledge that any agreements the insured/patient has made to restrict his or
her protected health information do not apply to this authorization (e.g., they are temporarily revoked only
as to this authorization) and I instruct the Providers to release and disclose the
entire medical record of the
insured/patient and any other of their protected health information as noted above
without restriction.
The information disclosed is for the purpose of claims processing, including but not limited to evaluating
contestability, eligibility determination, and/or benefit determinations by the Permitted Recipients.
This authorization shall remain in force for 24 months, or in the case of long-term care or disability claims for
the duration of the claims under such policy, whichever is longer, following the date of my signature below. I
understand that I have the right to revoke this authorization in writing, at any time, by sending a written
request for revocation to the Companies at Attention: Consumer Affairs Department, 4333 Edgewood Road
NE, Cedar Rapids, Iowa 52499. Alternatively, I may revoke this authorization by sending a written revocation
directly to the Providers with a copy sent to the Companies. I understand that a revocation is not effective to
the extent that any of the Providers has relied on this authorization or to the extent that the Companies have
relied on a signed authorization or have a legal right to contest a claim under an insurance policy or to
contest the policy itself. I understand that any information disclosed pursuant to this authorization may be
subject to redisclosure by the recipient and may no longer be protected by federal regulations governing
HIPAA AUTHORIZATION
PAGE 1 OF 2
2
Transamerica Financial Life Insurance Company / Transamerica Life Insurance Company
Transamerica Claims PO Box 219 Cedar Rapids IA 52406–0219
privacy and confidentiality of health information (such as the HIPAA Privacy Rule). However, the
Companies will protect the privacy of health information in accordance with other applicable state and/or
federal privacy laws and their own privacy policies. I understand that I have a right to receive the Notice of
Health Information Privacy Practices and a copy of this signed authorization upon request.
I understand that Providers that are subject to the HIPAA Privacy Rule (not including the Companies) may
not refuse to provide treatment or payment for health care services because I refuse to sign this
authorization. I do understand that if I refuse to sign this authorization to release the entire medical record
of the insured/patient, the Companies may not be able to proceed with claims or eligibility processing or
make any benefit payments. I acknowledge that (1) if I am signing on behalf of the insured/patient, I am
legally permitted to do so as the personal representative of the insured/patient, and (2) I have received a
copy of this authorization.
HIPAA AUTHORIZATION
PAGE 2 OF 2
Signature of insured/patient or their personal representative
Name of insured/patient (please print)
Date of birth (MM/DD/YYYY)
Date signed (MM/DD/YYYY)
Description of personal representative’s authority or
Relationship to insured/patient
Policy or contract number
Don’t forget to sign and date below: we can’t evaluate your claim without this!
2
Transamerica Financial Life Insurance Company / Transamerica Life Insurance Company
Transamerica Claims PO Box 219 Cedar Rapids IA 52406–0219
ATTENDING PHYSICIAN’S STATEMENT
PAGE 1 OF 1
This physician’s statement is required for all claims. Give this page to your
doctor to complete, then submit it together with the other parts of your claim.
3. Patient’s full name
4. Patient’s date of birth
9. For pregnancy claims, give due date and delivery type.
Street address
6. Diagnosis (use ICD 10 Codes)
Phone number
Degree
7. When did accident/symptoms first occur?
8. When did patient first consult you for this
condition?
1. Primary insured’s full name
2. Policy or certificate number
5. For this patient, are you being paid by…
Medicare? Medicaid ? Another insurance company?
☐ Yes ☐ Yes ☐ Yes — Company name: ______________________________
☐ No ☐ No ☐ No
11. List all dates of treatment (including surgical procedures, hospitalizations, ICU) and include the date charges of each
treatment/procedure. Use current CPT codes.
12. Is the patient still under your care for this condition? If
no, give name and address of new treating physician:
☐ Yes
☐ No
13. Did you advise the patient to
cease work?
☐ Yes, from ______ to ______
☐ No
14. Dates of total disability for
this condition (from/to):
14b. Next treatment date:
15. If the patient was released to light duty due to this
condition, give date range:
16. Was the patient unable to perform two or more activities of
daily living due to this condition? If so, which ones?
☐ Yes
☐ No
Physician’s signature
Printed name
Date (MM/DD/YYYY)
City
State
ZIP
Tax Identification Number
CONTACT INFORMATION
3
10. For cancer claims: to your knowledge, has the patient ever had
cancer prior to this diagnosis?
☐ No ☐ Yes (date) _________
Transamerica Financial Life Insurance Company / Transamerica Life Insurance Company
Transamerica Claims PO Box 219 Cedar Rapids IA 52406–0219
MEDICAL HISTORY FORM
PAGE 1 OF 2
You need to submit a medical history form for any disability claim,
and other
policies may require it too — so if you’re not sure if your claim requires it, go
ahead and fill it out. Submit it together with the other parts of your claim.
Street address
Reason for visit
Dates consulted or year treated
City
State
ZIP
Family physician name
Phone number
Street address
Reason for visit
Dates consulted or year treated
City
State
ZIP
OTHER PROVIDER — if applicable
Provider name
Phone number
Policy/certificate number(s)
INSURED PERSON’S DETAILS
Name of insured person
Social Security number
DETAILS ABOUT MEDICAL PROVIDERS
Please provide information about all the medical providers (including doctors and hospitals) the insured person
consulted for treatment related to this claim. We’ll then request information about their treatment of the insured
to help us understand how the policy covers the claim. You can attach extra pages if you need more space.
Street address
Reason for visit
Dates consulted or year treated
City
State
ZIP
OTHER PROVIDER — if applicable
Provider name
Phone number
Transamerica Financial Life Insurance Company / Transamerica Life Insurance Company
Transamerica Claims PO Box 219 Cedar Rapids IA 52406–0219
MEDICAL HISTORY FORM
PAGE 2 OF 2
DETAILS ABOUT MEDICATIONS
Please provide details about the medications the insured used for any treatment related to this claim (this
information is usually on the prescription bottle or container). Attach extra pages if you need more space.
For residents of New York: any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance or statement of claim containing any materially false information, or
conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent
insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and
the stated value of the claim for each such violation.
Claimant’s signature
Claimant’s printed name
Date (MM/DD/YYYY)
Street address
Reason for visit
Dates consulted or year treated
City
State
ZIP
OTHER PROVIDER — if applicable
Provider name
Phone number
Name and address of pharmacy
Medication name
Condition being treated
Prescribing physician name
Name and address of pharmacy
Medication name
Condition being treated
Prescribing physician name
Name and address of pharmacy
Medication name
Condition being treated
Prescribing physician name
Name and address of pharmacy
Medication name
Condition being treated
Prescribing physician name
Transamerica Financial Life Insurance Company / Transamerica Life Insurance Company
Transamerica Claims PO Box 219 Cedar Rapids IA 52406–0219
EMPLOYER’S STATEMENT
PAGE 1 OF 1
You need to submit this page only if your claim is a
disability claim.
Give this
page to your employer to complete, and then submit it together with the other
parts of your claim.
Signature of Employer’s authorized representative
Printed name
Date (MM/DD/YYYY)
Phone number
Title
3. Street address
4. City
5. State
6. ZIP
1. Company Name
2. Phone number
7. Full name of employee / insured person
8. Social Security number
9. Date this employee / insured person was last actively at work
10. Employee / insured person’s job title/major job duties (Attach a copy of job description)
11a. Did disability occur on the job?
☐ Yes ☐ No
11b. Job classification
☐ Sedentary ☐ Light ☐ Medium ☐ Heavy ☐ Very heavy
12. If the employee were medically cleared to return to work with restrictions, or on light duty, can you accommodate?
☐ Yes ☐ No — If no, attach letter explaining why accommodation is not possible
13. Date employee/insured person returned to work:
______________ ☐ Full time ☐ Part time ☐ Light duty
14. If “Part time” due to partial disability, provide earnings:
$___________ from/to dates ________________________
15. Employee/insured person’s status of employment after first day absent:
☐ Active ☐ Leave of absence ☐ Laid off ☐ Retired ☐ Terminated ☐ Other: ______________________________
16. Employee/insured person’s current status of employment:
☐ Active ☐ Leave of absence ☐ Laid off ☐ Retired ☐ Terminated Effective: _________
17. Annual salary
18. To the best of your knowledge, indicate if employee/insured person has filed for/is receiving income from any of these:
Salary continuance/Sick leave ☐ Yes ☐
No If yes, indicate number of hours as of last date worked: _______________
EIB or PTO ☐ Yes ☐
No If yes, indicate number of hours as of last date worked: _______________
Worker’s compensation ☐ Yes ☐ No If yes, indicate number of hours as of last date worked: _______________
The above statements are true and complete to the best of my knowledge and belief.
Transamerica Financial Life Insurance Company / Transamerica Life Insurance Company
Transamerica Claims PO Box 219 Cedar Rapids IA 52406–0219
Alabama.
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or
confinement in prison, or any combination thereof.
Alaska.
A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing
false, incomplete, or misleading information may be prosecuted under state law.
Arizona. For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly
presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
Arkansas, District of Columbia, Louisiana, New Mexico, Rhode Island, Texas, West Virginia.
Any person who knowingly
presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in application for
insurance is guilty of a crime and may be subject to fines and confinement in prison.
California.
For your protection, California law requires the following to appear on this form. Any person who knowingly
presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in
state prison.
Colorado.
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to any insurance
company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines,
denial of insurance and civil damages. Any insurance company or agents of an insurance company who knowingly
provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding
or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Delaware, Idaho, Indiana.
Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a
statement of claim containing any false, incomplete or misleading information is guilty of a felony.
Florida.
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an
application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Kentucky, Pennsylvania.
Any person who knowingly and with intent to defraud any insurance company or other person files
an application for insurance or statement of claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects
such person to criminal and civil penalties.
Maine, Tennessee, Virginia, Washington.
It is a crime to knowingly provide false, incomplete, or misleading information to an
insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance
benefits.
Maryland.
Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who
knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines
and confinement in prison.
Minnesota. A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
New Hampshire.
Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of
claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud,
as provided in N. H. Rev. Stat. Ann. § 638:20.
New Jersey.
Any person who knowingly files a statement of claim containing any false or misleading information is subject to
criminal and civil penalties.
New York.
Any person who knowingly and with intent to defraud any insurance company or other person files an application
for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be
subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Ohio.
Any person that knowingly presents false information in an application for insurance or life settlement contract is guilty
of a crime and may be subject to fines and confinement in prison.
Oklahoma.
WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
CLAIM FRAUD WARNINGS
PAGE 1 OF 1
Your state may require the following notice: Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benefit or knowingly presents false information in an
application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
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We understand you file claims during difficult times, (Little Rock School District)

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Completed 24 December 2021

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