[Code of Federal Regulations] [Title 38, Volume 1] [Revised as of January 1, 2007] From the U.S. Government Printing Office via GPO Access [CITE: 38CFR9.14] [Page 526-528] TITLE 38--PENSIONS, BONUSES, AND VETERANS' RELIEF CHAPTER I--DEPARTMENT OF VETERANS AFFAIRS PART 9_SERVICEMEMBERS' GROUP LIFE INSURANCE AND VETERANS' GROUP Sec. 9.14 Accelerated Benefits. (a) What is an Accelerated Benefit? An Accelerated Benefit is a payment of a portion of your Servicemembers' Group Life Insurance or Veterans' Group Life Insurance to you before you die. (b) Who is eligible to receive an Accelerated Benefit? You are eligible to receive [[Page 527]] an Accelerated Benefit if you have a valid written medical prognosis from a physician of 9 months or less to live, and otherwise comply with the provisions of this section. (c) Who can apply for an Accelerated Benefit? Only you, the insured member, can apply for an Accelerated Benefit. No one can apply on your behalf. (d) How much can you request as an Accelerated Benefit? (1) You can request as an Accelerated Benefit an amount up to a maximum of 50% of the face value of your insurance coverage. (2) Your request for an Accelerated Benefit must be $5,000 or a multiple of $5000 (for example, $10,000, $15,000). (e) How much can you receive as an Accelerated Benefit? You can receive as an Accelerated Benefit the amount you request up to a maximum of 50% of the face value of your insurance coverage, minus the interest reduction. The interest reduction is the amount the Office of Servicemembers' Group Life Insurance actuarially determines to be the amount of interest that would be lost because of the early payment of part of your insurance coverage. This means that if you have $100,000 in coverage and you request the maximum amount that you are eligible to request as an Accelerated Benefit, you will be paid $50,000 minus the interest reduction. (f) How do you apply for an Accelerated Benefit? (1) You can obtain an application form entitled ``Claim for Accelerated Benefits'' by writing the Office of Servicemembers' Group Life Insurance, 290 W. Mt. Pleasant Avenue, Livingston, New Jersey 07039; calling the Office of Servicemembers' Group Life Insurance toll-free at 1-800-219-1473; or downloading the form from the Internet at www.insurance.va.gov. You must submit the completed application form to the Office of Servicemembers' Group Life Insurance, 290 W. Mt. Pleasant Avenue, Livingston, New Jersey 07039. (2) As stated on the application form, you will be required to complete part of the application form and your physician will be required to complete part of the application form. If you are an active duty servicemember, your branch of service will also be required to complete part of the form. ________________________________________________________________________ To Be Completed by Insured Claim for Accelerated Benefits Your name:______________________________________________________________ Social Security Number:_________________________________________________ Your home address:______________________________________________________ Date of birth:__________________________________________________________ Branch of Service (if covered under SGLI):______________________________ Your mailing address (if different from above):_________________________ Amount of SGLI coverage: $______________________________________________ Amount of claim (can be no more than one-half of coverage in increments of $5,000):_____________________________________________________________ Type of coverage (check one): SGLI (circle one of the following): Active Duty Ready Reserve Army or Air National Guard Separated or Discharged VGLI Note: If you checked SGLI, you must also have your military unit complete the attached form. 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. Your signature:_________________________________________________________ Date:___________________________________________________________________ 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. Printed name:___________________________________________________________ Signature:______________________________________________________________ Date:___________________________________________________________________ A photocopy of this authorization will be considered as effective and valid as the original. Valid for one year from date signed. ________________________________________________________________________ To Be Completed by Physician Attending Physician's Certification Patient's name:_________________________________________________________ Patient's Social Security Number:_______________________________________ Diagnosis:______________________________________________________________ ICD-9-CM Disease Code *:________________________________________________ Description of present medical condition (please attach results of x- rays, E.K.G. or other tests):___________________________________________ Is the patient capable of handling his/her own affairs? -------- Yes---- No---- The patient applied for an accelerated benefit under his/her government life insurance [[Page 528]] coverage. To qualify, the patient must have a life expectancy of nine (9) months or less. Does your patient meet this requirement? -------- Yes---- No---- Attending Physician's name (please print):______________________________ State in which you are licensed to practice:____________________________ Specialty:______________________________________________________________ Mailing address:________________________________________________________ Telephone number:_______________________________________________________ Fax Number:_____________________________________________________________ Signature:______________________________________________________________ Date:___________________________________________________________________ *ICD-9-CM is an acronym for International Classification of Diseases, 9th revision, Clinical Modification. ________________________________________________________________________ To Be Completed by Personnel Office of Servicemember's Unit (Complete this form only if the applicant for Accelerated Benefits is covered under SGLI.) Branch of Service Statement Servicemember's name:___________________________________________________ Social Security Number:_________________________________________________ Branch of Service:______________________________________________________ Amount of SGLI coverage: $______________________________________________ Monthly premium amount: $_______________________________________________ Name of person completing this form:____________________________________ Telephone Number:_______________________________________________________ Fax Number:_____________________________________________________________ Title of person completing this form:___________________________________ Duty Station and address:_______________________________________________ Signature of person completing this form:_______________________________ Date:___________________________________________________________________ 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. (g) Who decides whether or not an Accelerated Benefit will be paid to you? The Office of Servicemembers' Group Life Insurance will review your application and determine whether you meet the requirements of this section for receiving an Accelerated Benefit. (1) They will approve your application if the requirements of this section are met. (2) If the Office of Servicemembers' Group Life Insurance determines that your application form does not fully and legibly provide the information requested by the application form, they will contact you and request that you or your physician submit the missing information to them. They will not take action on your application until the information is provided. (h) How will an Accelerated Benefit be paid to you? An Accelerated Benefit will be paid to you in a lump sum. (i) What happens if you change your mind about an application you filed for Accelerated Benefits? (1) An election to receive the Accelerated Benefit is made at the time you have cashed or deposited the Accelerated Benefit. After that time, you cannot cancel your request for an Accelerated Benefit. Until that time, you may cancel your request for benefits by informing the Office of Servicemembers' Group Life Insurance in writing that you are canceling your request and by returning the check if you have received one. If you want to change the amount of benefits you requested or decide to reapply after canceling a request, you may file another application in which you request either the same or a different amount of benefits. (2) If you die before cashing or depositing an Accelerated Benefit payment, the payment must be returned to the Office of Servicemembers' Group Life Insurance. Their mailing address is 290 W. Mt. Pleasant Avenue, Livingston, New Jersey 07039. (j) If you have cashed or deposited an Accelerated Benefit, are you eligible for additional Accelerated Benefits? No. (Approved by the Office of Management and Budget under control number 2900-0618) (Authority: 38 U.S.C. 1965, 1966, 1967, 1980) [67 FR 52413, Aug. 12, 2002]