Transcription of Group - Assocation Proof of Loss Life Insurance …
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Group - Assocation Proof of Loss Life Insurance …
Group /Association - Proof of loss Connecticut General life Insurance Company life Insurance Company of North America life Insurance Accidental Death Insurance Cigna life Insurance Company of New York Great-West Healthcare Administered by Cigna CLEAR FORM. MAIL TO: Cigna Box 22328. Pittsburgh, PA 15222-0328. 1-800-238-2125 Toll Free NEW YORK FRAUD WARNING: 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 $5000 and the stated value of the claim for each such violation.
i. INSTRUCTIONS FOR FILING A CLAIM SECTION A: EMPLOYEE INFORMATION. Name of Employee/Member (Last Name) (First Name) (Middle Initial)
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