PURPOSE: To provide a method of requesting verification of cash surrender value of insurance policies or prepaid burial plans held by the claimant. This form can also provide information concerning liens or loans against these policies or plans.
NUMBER OF COPIES AND DISPOSITION: Make two copies. Mail the original to the appropriate company and retain a copy in the case record. Destroy the copy when the company returns the original. The original can be destroyed after the IM-37 is updated.
NOTE: If the data on the IM-9 shows that the claimant’s eligibility can be affected, keep the original in the case file.
MANUAL REFERENCE: December 1973 Eligibility Requirements 1030.020.05 and 1030.020.10
INSTRUCTIONS FOR COMPLETION:
FROM:
ELIGIBILITY SPECIALIST: Enter the name of the Eligibility Specialist.
TELEPHONE NUMBER: Enter the office phone number where the Eligibility Specialist may be reached.
DATE: The letter is dated the same day as the approval is entered in IMU5. If using the online version, the date is system generated.
COUNTY OFFICE ADDRESS (STREET, CITY, STATE, AND ZIP CODE): On the next two lines, enter the complete county office address.
TO
NAME: Enter the name of the claimant.
ADDRESS (STREET): Enter the street address of the claimant.
CITY, STATE, AND ZIP CODE: Enter the city, state, and zip code of the claimant.
RE
CASE NAME: Enter the case name of the head of the household.
CASE DCN: Enter the case Departmental Client Number (DCN) of the head of the household.
AUTHORIZATION FOR RELEASE OF INFORMATION: This form must be signed and dated by the claimant.
ELIGIBILITY SPECIALIST: The Eligibility Specialist signs the form and enters his/her caseload number.
NAME OF INSURED: Enter the full name of each individual who has an insurance policy or prepaid burial on which information is requested.
POLICY OR PLAN NUMBER: Enter the complete number of each policy or burial plan on which information is requested.
DATE OF ISSUE: If available, enter the date the policy or burial plan was issued. If not available, leave blank so this can be completed by the appropriate company.
FACE VALUE: If available, enter the face value of the policy or burial plan in question. If not available, leave blank so this can be completed by the appropriate company.
The following sections are completed by the company for which the information is requested:
OTHER COMMENTS: This may be completed by the Eligibility Specialist to provide additional information to the appropriate company. If may also be used by the appropriate company to make additional comments.
SIGNED, TITLE, AND DATE: The company designee who completes the form provides his/her name, title, and date.
ENCLOSURES: Provide a self-addressed envelope with each request for information.
NOTE: If the company requires an authorization to retain for their record, a second IM-9 should be completed and signed or a signed IM-6 may be attached.