Fillable Printable Fe7
Fillable Printable Fe7
Fe7
Claim for Accidental Means Dismemberment Benefits
Federal Employees’Group Life Insurance Program
Instructions to Claimant
1.General -
To avoid delay:
(a) Read these instructions carefully.
(b) Type or print in ink.
2.Completion of claim -
Part A should be completed by the claimant (usually the
insured employee).The claimant should then have Part C
on the reverse side completed by the attending physician.
3.Medical and accident reports -
Please attach copies of all medical reports from the first
date until the last date of treatment received as a result of
the accident.Any police/traffic accident or other accident
related reports should be attached.
4.If assistance is needed -
If you need assistance in completing this claim contact the
employing office of the department or agency in which you
are employed.
5.Where to send claim -
Forward the completed claim to the employing office of the
department or agency in which you are employed.
1.Full name of the insured
(Last, first, middle)
2.Date of birth
(Month, day, year)
3.Social Security Number
4.Department or agency in which employed,5.Location of employment (City, State & Zip Code)6.When did the accident happen? (Month, day, year)
including bureau or division
7.Where did the accident happen? (City and State)
8.Give a brief description of the accident (Attach all medical and accident reports as instructed above)
I hereby certify that all statements made in this claim are true to the best of my knowledge, information, and belief, and that no evidence necessary to a
settlement of this claim is suppressed or withheld.I also authorize the physician to release any information requested with respect to this claim.
Signature of claimantAddress
Telephone numberDate
(day)
(evening)
Part A - General Information Concerning the Insured
Instructions to Employing Agency
It is the agency’s responsibility to assist the claimant in properly completing this claim.After Parts A and C have been completed, the agency should fully
complete Part B and forward the claim to:
Office of Federal Employees’Group Life Insurance
200 Park Avenue
New York,NY 10166-0188
1.Annual rate of basic pay established for basic life insurance purposes on the date of the accident.$
2.Was employee covered by Option A - Standard life insurance on the date of the accident? YESDate of election
I certify that the above information has been obtained from and correctly reflects official records and the employee named was covered by
Federal Employees’Group Life Insurance on the date of the accident.
Signature of authorized agency officialName of agency
Name of authorized agency official (type or print)Mailing address of agency, including ZIP Code
Title
DateCommercial telephone numberFax number
( )( )
Area codeArea code
Part B - Certification of Insurance Status
FE-7
Previous editions are usableRevised January 1997
OFEGLI Form in Adobe Acrobat PDF (11/97)
NO
b62899fegli bon.eye 1/13/98 8:49 AM Page 1
1a.Name of patient1b.Age
2a.Date of accident
(month, day, year)
2b.Date first consulted on account of injury descr ibed
(month, day, year)
2c.Date of last treatment
(month, day, year)
3.Describe the exact nature, location, and extent of all injuries sustained.(Attach all medical reports relevant to the treatment of the injury incurred)
4.Was the injury described solely responsible for the loss? YES
5a.Give the date of exam and vision prior to the accident.
5b.State the loss of vision.
5c.Give the date you first determined vision was irrecoverably reduced to
20/200 (Snellen Notation) or less with correction and the vision
then remaining in each eye.
5d.Give the date and vision found on last eye examination.
6.Indicate whether recovery of useful vision is possible by operation or treatment.
Right eyeOperationTreatment
Left eyeOperationTreatment
7.If eye is enucleated, give date.
8.If fields of vision are contracted, show contraction on chart below.
5a.Which limbs were severed or amputated?
5b.On what dates did the severances or amputations occur?
5c.State the exact point at which the amputation was performed or the severance
occurred with respect to each limb lost.If the severance or amputation was below
the elbow or knee joint, indicate on the chart the exact point of severance.
5d.State the causes of the amputations.
6.Did the patient ever consult you before? If so, please state the dates
and the ailments forwhich you attended, treated, or examined the patient.
7.Please give the names of such other physicians who have attended this
patient,and the dates of their first and last treatments as reported to you.
Part C - Physician’s Statement
To Be Completed Only for Loss of Vision
FE-7 (0197) Printed in U.S.A.
18000080934 (0197)
Reverse of FE-7
OFEGLI Form in Adobe Acrobat PDF (11/97)
(Snellen
Notations)
Right
eye
Left
eye
Uncorrected Corrected
(Snellen
Notations)
Right
eye
Left
eye
Uncorrected Corrected
(Snellen
Notations)
Right
eye
Left
eye
Uncorrected Corrected
Left Eye Right Eye
NOGive the particulars of any cause or causes, including disease, which contributed to
the loss.
CHART
To Be Completed Only for Limb Amputations
I hereby certify that all statements made above are true to the
best of my knowledge and belief.
Signature of PhysicianDateCity, State and ZIP Code
Telephone numberFax number
( )( )
Area codeArea code
Office Address - Number and Street
b62899fegli bon.eye 1/13/98 8:49 AM Page 2
