| Claimant Name: | Name of deceased or dismembered claimant |
| Member Name: | Name of the employee or member of the group |
| Incurred Date: | Death claim will be the date of death. For Non Death claim, incurred date for accident causing the dismemberment |
| DOB: | Date of birth of deceased or dismembered person |
| Claim Type: | D - Death and ND - Non-Death claims such as Accidental Dismemberment, AB - Accelerated Benefit |
| Product: | BL - Basic Life, BA - Basic AD&D, AL - Additional Life, AA - Additional AD&D, DL - Dependent Life, SL - Supplemental Life, PL - Paid Up Life, VL - Voluntary Life, VA - Voluntary AD&D |
| Product Status: | Approved - product has been approved, Pending - still in review, Denied - product was denied |
| Amount Paid: | The amount paid to date for each product |
| Last Date Paid: | The date last payment was made |
| Claim Status: | Provides the overall status of the claim |
| Claimant Name Member Name |
Claim Nbr / Recv Date Last 4 SSN / DOB |
Incurred Date | Claim Type | Product / Status | Amt in Review Amt Paid |
Last Date Paid Claim Status |
|
|---|---|---|---|---|---|---|---|
| JOHN ADAMS JOHN ADAMS |
B01111 4785 |
mm/dd/yyyy mm/dd/yyyy |
mm/dd/yyyy | D | BL Approved |
1,000.00 0.00 |
Closed |
| GREG BRANSON GREG BRANSON |
B02222 7787 |
mm/dd/yyyy mm/dd/yyyy |
mm/dd/yyyy | D | BL Approved |
2,000.00 1,000.00 |
mm/dd/yyyy Closed |
| LISA DAVIS LISA DAVIS |
B03333 4454 |
mm/dd/yyyy mm/dd/yyyy |
mm/dd/yyyy | D | BL Approved |
1,000.00 2,000.00 |
mm/dd/yyyy Active |
| SARAH JONES SARAH JONES |
B04444 6789 |
mm/dd/yyyy mm/dd/yyyy |
mm/dd/yyyy | D | BL Approved |
1,000.00 1,000.00 |
mm/dd/yyyy Closed |
| TAMMY ROBERTS TAMMY ROBERTS |
B05555 7878 |
mm/dd/yyyy mm/dd/yyyy |
mm/dd/yyyy | D | BL Approved |
1,000.00 0.00 |
Active |