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Claim For Dismemberment Benefits FE-7 - Official Federal Forms
|Claim For Dismemberment Benefits Form. This is a national form and can be used in Federal Employees Group Life Insurance US Office Of Personnel Management .||
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Claim for Dismemberment Benefits Federal Employees' Group Life Insurance (FEGLI) Program Instructions "You", "your" and "I" refer to the insured employee. Who completes this form? Employees enrolled in the FEGLI Program who lose a limb or eyesight complete this form. How can I get help completing this form? Contact your human resources office or call the Office of Federal Employees' Group Life Insurance (OFEGLI) at 1-800-633-4542. How do I complete this form? Complete Part A and ask your physician or other healthcare provider to complete Part C. Then give the form to your human resources office. Can someone complete this form on my behalf? Yes. If you are physically or mentally unable to complete this claim form, someone else can complete it for you and attach a short explanation of the reason you are unable to complete this form. Items 1-8 of Part A and all of Parts B and C should be about you, but the person completing this form should sign his/her name and give his/her address and telephone number. Should I attach anything to this form? Yes. Attach copies of all medical reports from treatment you received for this accident. Also attach any police, traffic or other reports about this accident. 1. Your name (Last, first, middle) Part A - Employee's Statement 2. Date of birth (mm/dd/yyyy) 3. Social Security number 4. Your department or agency, including bureau or division 5. Location of employment (City, state and ZIP code) 6. Date of accident (mm/dd/yyyy) 7. Place of accident (City and State) 8. Give a brief description of the accident. All statements I made on this claim form are true. I have not knowingly left out anything related to this claim. I authorize my physician or other healthcare provider to release any information requested about this claim. Your Signature Address Telephone number (day) (evening) Date (mm/dd/yyyy) Employing Agency's Instructions Please help the employee complete this claim form, if necessary. The employee should return this form after the physician or other health care provider completes Part C. Complete Part B and send this form to: Office of Federal Employees' Group Life Insurance PO Box 6512 Utica, NY 13504-6512 Part B - Agency's Certification 1. Annual rate of basic pay for Basic Life insurance purposes on the date of the accident 2. Was the employee covered by Option A on the date of the accident? NO YES If "YES," $ Date of election (mm/dd/yyyy) I certify that this information correctly reflects official records and that the employee was covered by Federal Employees' Group Life Insurance on the date of the accident. Signature of authorized agency official Name of agency Name of authorized agency official (type or print) Mailing address of agency, including ZIP code Title Date (mm/dd/yyyy) Telephone number Fax number ( Area code Do NOT use previous editions ) ( Area code ) American LegalNet, Inc. www.FormsWorkFlow.com Form FE-7 Revised May 2009 OFEGLI Form in Adobe Acrobat PDF (05/09) Part C - Physician's Statement 1. Name of patient 3. Date of accident (mm/dd/yyyy) 4. Date first consulted because of this injury (mm/dd/yyyy) 2. Date of Birth (mm/dd/yyyy) 5. Date of last treatment (mm/dd/yyyy) 6. Describe the exact nature, location, and extent of all injuries sustained. (Attach all medical reports relevant to the treatment of the injury) 7. Were the injuries described solely responsible for the loss of limb or eyesight? YES NO Give the particulars of any cause or causes (including disease) which contributed to the loss, in the space to the left. (Explain on a separate sheet if necessary) Complete for Limb Amputations Only 8. Which limbs were severed or amputated? Complete for Loss of Vision Only 13. Give the date of exam and vision before the accident. Uncorrected Date: (mm/dd/yyyy) (Snellen Right eye Notations) Left eye Corrected 9. On what date(s) did the severances or amputations occur? 10. State the exact point where the amputation was performed or where the severance occurred for each limb lost. If the severance or amputation was below the elbow or knee joint, indicate in item 12 on the chart below the exact point of severance. 14. State the loss of vision. 15. Give the date you first determined vision was irrecoverably reduced to 20/200 (Snellen Notation) or less with correction, and the vision remaining in each eye on that date. Uncorrected Date: (mm/dd/yyyy) (Snellen Right eye Notations) Left eye Corrected 11. Reason for amputation(s)? 16. Give the date and vision found on last eye examination. Uncorrected Date: (mm/dd/yyyy) (Snellen Right eye Notations) Left eye Corrected 17. Is recovery of useful vision possible by operation or treatment? Yes No Yes No Right eye Left eye 12. Operation Operation Treatment Treatment CHART RIGHT LEFT RIGHT LEFT 18. If eye is enucleated, give date. 19. If fields of vision are contracted, show contraction on chart below. Left Eye 90º 120º 80º 70º 60º 50º 40º 150º 30º 20º 10º 60º 120º Right Eye 90º 80º 70º 60º 50º 40º 30º 20º 10º 30º 60º I certify that all of my statements are true to the best of my knowledge and belief. Physician's Signature Physician's Name (type or print) Date (mm/dd/yyyy) RIGHT LEFT 180º 80º70º60º50º40º30º20º10º 10º20º30º40º50º60º60º50º40º30º20º10º 10º20º30º40º50º60º70º80º 0º 10º 20º 210º 30º 40º 50º 60º 240º 70º 80º 270º 300º 240º 10º 20º 30º 40º 50º 60º 70º 80º 270º 300º 330º Office address - number and street City, state and ZIP code Telephone number ( ) Area code American LegalNet, Inc. www.FormsWorkFlow.com Fax number ( ) Area code Reverse of FE-7 Revised May 2009 OFEGLI Form in Adobe Acrobat PDF (05/09) FE-7 (0509) Printed in U. S. A.