3rd Party iClaim

OMB 0960-0618 Screen Package
Modified Screen #1

Changed title to “Country”
instead of “U.S Mailing
Address “

Added a drop down box to
provide additional countries

OMB 0960-0618

Page 1

OISP/OAESP

Modified Screen #2

Modified language
Please provide information about the prior marriages for which you answered “Yes” above. List your most recent
marriage first (regardless of how long it lasted) and work backwards. If you are not sure of the marriage date, enter
your best guess and explain in the Remarks page near the end of the application.

Modified language
Did you have any other prior marriage that lasted at least 10 years, or any other prior marriages that ended due to
your spouse’s death?

OMB 0960-0618

Page 2

OISP/OAESP

Modified Screen #3

Modified language
The header will read: When to Start Retirement Benefits for Jane Public.
The first sentence will read: It’s your choice when to start retirement benefits.

OMB 0960-0618

Page 3

OISP/OAESP

Retirement and Disability Path
Existing Screen (Medicare-Only) #1

OMB 0960-0618

Page 4

OISP/OAESP

Retirement and Disability Path
Existing Screen (Medicare-Only) #2

OMB 0960-0618

Page 5

OISP/OAESP

New to the Retirement and Disability Path
Existing Screen (Medicare-Only) #3

OMB 0960-0618

Page 6

OISP/OAESP

iClaim New Screen #1

OMB 0960-0618

Page 7

OISP/OAESP