Initial Claimant's Statement for Income Replacement/Waiver of Premium Benefits
Last updated: May 13, 2025
This document is an initial claimant's statement used for requesting income replacement or a waiver of premium benefits due to a disabling condition. It includes fields for personal details, employment information, medical history, and occupational duties to assess eligibility for benefits.
Fields
Field | Description | Example |
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Full legal name of the insured individual filing the claim. |
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Residential address of the insured. |
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Name of the insured's most recent employer. |
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Business address of the insured's last employer. |
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USAA membership identification number. |
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Primary contact phone number of the insured. |
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Date of birth of the insured individual. |
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Business contact phone number of the insured. |
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Description of the current disabling condition and its cause. |
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Month when the accident or illness occurred. |
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Day when the accident or illness occurred. |
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Year when the accident or illness occurred. |
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Month when the insured completely stopped working due to the disability. |
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Day when the insured completely stopped working due to the disability. |
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Year when the insured completely stopped working due to the disability. |
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Indicates whether the insured has returned to work, part-time, full-time, or has not returned. |
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Name of the first physician or medical practitioner consulted. |
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Address of the first physician or medical practitioner consulted. |
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Date of consultation with the first physician. |
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Name of the second physician or medical practitioner consulted. |
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Address of the second physician or medical practitioner consulted. |
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Date of consultation with the second physician. |
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Name of the third physician or medical practitioner consulted. |
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Address of the third physician or medical practitioner consulted. |
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Date of consultation with the third physician. |
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Name of the first hospital where the insured was confined. |
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Address of the first hospital where the insured was confined. |
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Start date of the first hospital confinement. |
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End date of the first hospital confinement. |
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Reason for the first hospital confinement. |
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Name of the second hospital where the insured was confined. |
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Address of the second hospital where the insured was confined. |
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Start date of the second hospital confinement. |
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End date of the second hospital confinement. |
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Reason for the second hospital confinement. |
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Job title held immediately before becoming disabled. |
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Date when the insured started working in the listed occupation. |
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Specific job duties the insured is unable to perform as a result of the disability. |
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Details about prior work experience and educational background. |
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Additional notes or remarks from the insured. |
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