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pdfREADY RETIREMENT (“ICLAIM”)
SCREENS FOR
OMB CLEARANCE PACKAGE
Title: iClaim Screens for OMB Clearance Package
TABLE OF CONTENTS
1.0
APPLICATION ENTRY PAGES .......................................................................................... 1
1.1
1.2
1.3
1.4
RETIREMENT/MEDICARE BENEFITS ............................................................................................................................. 1
DISABILITY BENEFITS .................................................................................................................................................. 2
USERS COMING FROM THE RETIREMENT ESTIMATOR VERSION ..................................................................................... 3
RESTART PAGE (WILL BE SHOWN TO USERS ACCESSING THE RETIREMENT ESTIMATOR FROM THE WHEN TO START
BENEFITS PAGE AND THEN RETURNING TO THE APPLICATION AND TO USERS WHO SELECT “CONTINUE APPLICATION” ON THE
WELCOME PAGE) .................................................................................................................................................................... 4
2.0
IDENTIFICATION: PREPARER’S PAGE FOR 3RD PARTY......................................... 5
3.0
IDENTIFICATION: INITIAL INFORMATION SECTION ............................................ 6
3.1
3.2
3.3
3.4
3.5
APPLICANT IDENTIFICATION - RETIREMENT/MEDICARE VERSION ................................................................................. 6
APPLICANT IDENTIFICATION - DISABILITY VERSION ..................................................................................................... 7
CONTACT INFORMATION............................................................................................................................................. 9
BIRTH AND CITIZENSHIP INFORMATION..................................................................................................................... 11
MEDICARE ELECTION INFORMATION – AGE 64 AND OLDER ....................................................................................... 13
4.0
IDENTIFICATION: APPLICATION NUMBER ............................................................. 14
4.1
4.2
4.3
RETIREMENT VERSION ............................................................................................................................................. 14
DISABILITY VERSION ................................................................................................................................................ 16
MEDICARE ONLY VERSION ....................................................................................................................................... 18
5.0 IDENTIFICATION: PERSONAL INFO SECTION (RETIREMENT/DISABILITY
ONLY) .............................................................................................................................................. 20
5.1
5.2
5.3
OTHER NAMES AND SSNS ......................................................................................................................................... 20
DISABILITY (RETIREMENT, STARTED FROM RETIREMENT ENTRY POINT) .................................................................... 22
DISABILITY (DISABILITY ALLEGED, STARTED FROM DISABILITY ENTRY POINT) .......................................................... 24
6.0
GENERAL: FAMILY SECTION (RETIREMENT/DISABILITY ONLY) ................... 25
6.1
6.2
6.3
MARRIAGE INFORMATION......................................................................................................................................... 25
PRIOR MARRIAGES ................................................................................................................................................... 27
CHILDREN ................................................................................................................................................................ 31
7.0
GENERAL: MILITARY SECTION (RETIREMENT/DISABILITY ONLY) .............. 36
7.1
7.2
FIRST PARTY ............................................................................................................................................................ 36
THIRD PARTY ........................................................................................................................................................... 37
8.0
GENERAL: EARNINGS SECTION (RETIREMENT/DISABILITY ONLY) .............. 38
8.1
8.2
8.3
8.4
8.5
EMPLOYER DETAILS ................................................................................................................................................. 38
SELF-EMPLOYMENT DETAILS .................................................................................................................................... 40
SUPPLEMENTAL INFORMATION ................................................................................................................................. 42
TOTAL EARNINGS ..................................................................................................................................................... 44
OTHER PENSIONS/ANNUITIES ................................................................................................................................... 49
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page i
Title: iClaim Screens for OMB Clearance Package
9.0
GENERAL: WHEN TO START BENEFITS (RETIREMENT/DISABILITY ONLY) 51
9.1
9.2
9.3
REDUCED BENEFITS (RETIREMENT ONLY) ................................................................................................................ 51
WHEN TO START BENEFITS (RETIREMENT ONLY) ...................................................................................................... 53
DIRECT DEPOSIT ...................................................................................................................................................... 61
10.0 OTHER BENEFITS: BENEFIT INFO .............................................................................. 63
10.1
10.2
RETIREMENT/DISABILITY VERSION........................................................................................................................... 63
MEDICARE ONLY VERSION ....................................................................................................................................... 66
11.0 OTHER BENEFITS: DISABILITY QUESTIONS (DISABILITY ONLY) ................... 71
11.1
11.2
11.3
11.4
ABILITY TO WORK ................................................................................................................................................... 71
DISABILITY PAYMENTS............................................................................................................................................. 73
DEPENDENTS ............................................................................................................................................................ 75
AUTHORIZATION ...................................................................................................................................................... 77
12.0 REMARKS ............................................................................................................................. 78
12.1
12.2
RETIREMENT/DISABILITY ......................................................................................................................................... 78
MEDICARE ONLY ..................................................................................................................................................... 79
13.0 REVIEW: OVERALL SUMMARY ................................................................................... 80
13.1
13.2
13.3
RETIREMENT VERSION ............................................................................................................................................. 80
DISABILITY VERSION ................................................................................................................................................ 87
MEDICARE ONLY VERSION ....................................................................................................................................... 93
14.0 SUBMIT: SEND THIS APPLICATION ............................................................................ 97
14.1
14.2
14.3
RETIREMENT VERSION ............................................................................................................................................. 97
DISABILITY VERSION ................................................................................................................................................ 98
MEDICARE ONLY VERSION ..................................................................................................................................... 100
15.0 NEXT STEPS: RECEIPT SECTION ............................................................................... 102
15.1
15.2
15.3
15.4
15.5
15.6
15.7
15.8
15.9
15.10
15.11
15.12
RETIREMENT ONLY, FIRST PARTY ........................................................................................................................... 102
RETIREMENT ONLY, THIRD PARTY ......................................................................................................................... 105
RETIREMENT ONLY, CURRENT MARRIAGE AND NO OTHER EVIDENCE REQUIRED, FIRST PARTY ................................ 106
RETIREMENT ONLY, CURRENT MARRIAGE AND NO OTHER EVIDENCE REQUIRED, THIRD PARTY ............................... 107
RETIREMENT ONLY, NO EVIDENCE REQUIRED, FIRST PARTY .................................................................................. 108
RETIREMENT ONLY, NO EVIDENCE REQUIRED, THIRD PARTY ................................................................................ 109
DISABILITY ALLEGED, FIRST PARTY ....................................................................................................................... 110
DISABILITY ALLEGED, THIRD PARTY ...................................................................................................................... 112
MEDICARE ONLY, FIRST PARTY (EVIDENCE REQUIRED) .......................................................................................... 114
MEDICARE ONLY, THIRD PARTY (EVIDENCE REQUIRED) ......................................................................................... 115
MEDICARE ONLY, NO EVIDENCE REQUIRED, FIRST PARTY ..................................................................................... 116
MEDICARE ONLY, NO EVIDENCE REQUIRED, THIRD PARTY .................................................................................... 117
16.0 NEXT STEPS: WHAT’S NEXT SECTION .................................................................... 117
16.1
16.2
RETIREMENT ONLY (NO DISABILITY ALLEGED), FIRST PARTY ................................................................................ 117
RETIREMENT ONLY (NO DISABILITY ALLEGED), THIRD PARTY............................................................................... 119
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page ii
Title: iClaim Screens for OMB Clearance Package
16.3
16.4
16.5
16.6
16.7
16.8
DISABILITY ALLEGED W/ LINK TO 3368 REQUIRED, FIRST PARTY ............................................................................ 120
DISABILITY ALLEGED W/ LINK TO 3368 REQUIRED, THIRD PARTY ........................................................................... 121
DISABILITY ALLEGED BUT NOT CONTINUING TO 3368, FIRST PARTY ...................................................................... 122
DISABILITY ALLEGED BUT NOT CONTINUING TO 3368, THIRD PARTY ...................................................................... 123
MEDICARE ONLY, FIRST PARTY.............................................................................................................................. 124
MEDICARE ONLY, THIRD PARTY ............................................................................................................................ 125
17.0 MESSAGE PAGES ............................................................................................................. 126
MSG005
............................................................................................................................................................................. 126
MSG006 ............................................................................................................................................................................. 126
MSG010 ............................................................................................................................................................................. 127
MSG025 ............................................................................................................................................................................. 128
MSG028 ............................................................................................................................................................................. 128
MSG029 ............................................................................................................................................................................. 129
MSG045 ............................................................................................................................................................................. 129
MSG047 ............................................................................................................................................................................. 130
MSG111 ............................................................................................................................................................................. 130
MSG112 ............................................................................................................................................................................. 131
MSG113 ............................................................................................................................................................................. 132
MSG152 ............................................................................................................................................................................. 133
MSG153 ............................................................................................................................................................................. 134
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page iii
Title: iClaim Screens for OMB Clearance Package
1.0 APPLICATION ENTRY PAGES
1.1
RETIREMENT/MEDICARE BENEFITS
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 1
Title: iClaim Screens for OMB Clearance Package
1.2
DISABILITY BENEFITS
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 2
Title: iClaim Screens for OMB Clearance Package
1.3
USERS COMING FROM THE RETIREMENT ESTIMATOR VERSION
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 3
Title: iClaim Screens for OMB Clearance Package
1.4
RESTART PAGE (WILL BE SHOWN TO USERS ACCESSING THE
RETIREMENT ESTIMATOR FROM THE WHEN TO START BENEFITS
PAGE AND THEN RETURNING TO THE APPLICATION AND TO USERS
WHO SELECT “CONTINUE APPLICATION” ON THE WELCOME PAGE)
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 4
Title: iClaim Screens for OMB Clearance Package
2.0 IDENTIFICATION: PREPARER’S PAGE FOR 3RD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 5
Title: iClaim Screens for OMB Clearance Package
3.0 IDENTIFICATION: INITIAL INFORMATION SECTION
3.1
APPLICANT IDENTIFICATION - RETIREMENT/MEDICARE VERSION
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 6
Title: iClaim Screens for OMB Clearance Package
3.2
3.2.1
APPLICANT IDENTIFICATION - DISABILITY VERSION
FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 7
Title: iClaim Screens for OMB Clearance Package
3.2.2
THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 8
Title: iClaim Screens for OMB Clearance Package
3.3
3.3.1
CONTACT INFORMATION
FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 9
Title: iClaim Screens for OMB Clearance Package
3.3.2
THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 10
Title: iClaim Screens for OMB Clearance Package
3.4
3.4.1
BIRTH AND CITIZENSHIP INFORMATION
FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 11
Title: iClaim Screens for OMB Clearance Package
3.4.2
THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 12
Title: iClaim Screens for OMB Clearance Package
3.5
MEDICARE ELECTION INFORMATION – AGE 64 AND OLDER
3.5.1
FIRST PARTY
3.5.2
THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 13
Title: iClaim Screens for OMB Clearance Package
4.0 IDENTIFICATION: APPLICATION NUMBER
4.1
4.1.1
RETIREMENT VERSION
FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
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Title: iClaim Screens for OMB Clearance Package
4.1.2
THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 15
Title: iClaim Screens for OMB Clearance Package
4.2
4.2.1
DISABILITY VERSION
FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 16
Title: iClaim Screens for OMB Clearance Package
4.2.2
THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 17
Title: iClaim Screens for OMB Clearance Package
4.3
4.3.1
MEDICARE ONLY VERSION
FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 18
Title: iClaim Screens for OMB Clearance Package
4.3.2
THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 19
Title: iClaim Screens for OMB Clearance Package
5.0 IDENTIFICATION: PERSONAL INFO SECTION
(RETIREMENT/DISABILITY ONLY)
5.1
5.1.1
OTHER NAMES AND SSNS
FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
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Title: iClaim Screens for OMB Clearance Package
5.1.2
THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 21
Title: iClaim Screens for OMB Clearance Package
5.2
5.2.1
DISABILITY (RETIREMENT, STARTED FROM RETIREMENT ENTRY
POINT)
FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 22
Title: iClaim Screens for OMB Clearance Package
5.2.2
THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 23
Title: iClaim Screens for OMB Clearance Package
5.3
DISABILITY (DISABILITY ALLEGED, STARTED FROM DISABILITY
ENTRY POINT)
5.3.1
FIRST PARTY
5.3.2
THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 24
Title: iClaim Screens for OMB Clearance Package
6.0 GENERAL: FAMILY SECTION (RETIREMENT/DISABILITY
ONLY)
6.1
6.1.1
MARRIAGE INFORMATION
FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 25
Title: iClaim Screens for OMB Clearance Package
6.1.2
THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 26
Title: iClaim Screens for OMB Clearance Package
6.2
6.2.1
PRIOR MARRIAGES
FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 27
Title: iClaim Screens for OMB Clearance Package
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 28
Title: iClaim Screens for OMB Clearance Package
6.2.2
THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 29
Title: iClaim Screens for OMB Clearance Package
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
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Title: iClaim Screens for OMB Clearance Package
6.3
6.3.1
CHILDREN
NO DISABILITY ALLEGED, FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 31
Title: iClaim Screens for OMB Clearance Package
6.3.2
NO DISABILITY ALLEGED, THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 32
Title: iClaim Screens for OMB Clearance Package
6.3.3
DISABILITY ALLEGED, FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 33
Title: iClaim Screens for OMB Clearance Package
6.3.4
DISABILITY ALLEGED, THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 34
Title: iClaim Screens for OMB Clearance Package
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 35
Title: iClaim Screens for OMB Clearance Package
7.0 GENERAL: MILITARY SECTION (RETIREMENT/DISABILITY
ONLY)
7.1
FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 36
Title: iClaim Screens for OMB Clearance Package
7.2
THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 37
Title: iClaim Screens for OMB Clearance Package
8.0 GENERAL: EARNINGS SECTION (RETIREMENT/DISABILITY
ONLY)
8.1
8.1.1
EMPLOYER DETAILS
FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 38
Title: iClaim Screens for OMB Clearance Package
8.1.2
THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 39
Title: iClaim Screens for OMB Clearance Package
8.2
8.2.1
SELF-EMPLOYMENT DETAILS
FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 40
Title: iClaim Screens for OMB Clearance Package
8.2.2
THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 41
Title: iClaim Screens for OMB Clearance Package
8.3
8.3.1
SUPPLEMENTAL INFORMATION
FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 42
Title: iClaim Screens for OMB Clearance Package
8.3.2
THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 43
Title: iClaim Screens for OMB Clearance Package
8.4
8.4.1
TOTAL EARNINGS
RETIREMENT VERSION, FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
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Title: iClaim Screens for OMB Clearance Package
8.4.2
RETIREMENT VERSION, THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 45
Title: iClaim Screens for OMB Clearance Package
8.4.3
DISABILITY VERSION, FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 46
Title: iClaim Screens for OMB Clearance Package
8.4.4
DISABILITY VERSION, THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 47
Title: iClaim Screens for OMB Clearance Package
8.4.5
NO WORK OR SELF EMPLOYMENT ALLEGED VERSION, FIRST PARTY
8.4.6
NO WORK OR SELF EMPLOYMENT ALLEGED VERSION , THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 48
Title: iClaim Screens for OMB Clearance Package
8.5
8.5.1
OTHER PENSIONS/ANNUITIES
FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 49
Title: iClaim Screens for OMB Clearance Package
8.5.2
THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 50
Title: iClaim Screens for OMB Clearance Package
9.0 GENERAL: WHEN TO START BENEFITS
(RETIREMENT/DISABILITY ONLY)
9.1
9.1.1
REDUCED BENEFITS (RETIREMENT ONLY)
FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 51
Title: iClaim Screens for OMB Clearance Package
9.1.2
THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 52
Title: iClaim Screens for OMB Clearance Package
9.2
9.2.1
WHEN TO START BENEFITS (RETIREMENT ONLY)
APPLICANT HAS ONE MONTH OF ELECTION OPTION (FIRST PARTY)
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 53
Title: iClaim Screens for OMB Clearance Package
9.2.2
APPLICANT HAS ONE MONTH OF ELECTION OPTION (THIRD PARTY)
9.2.3
APPLICANT HAS A DEFAULT MONTH OF ELECTION AND OTHER OPTIONS (FIRST
PARTY)
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
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Title: iClaim Screens for OMB Clearance Package
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
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Title: iClaim Screens for OMB Clearance Package
9.2.4
APPLICANT HAS A DEFAULT MONTH OF ELECTION AND OTHER OPTIONS (THIRD
PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 56
Title: iClaim Screens for OMB Clearance Package
9.2.5
APPLICANT HAS MULTIPLE MONTH OF ELECTION OPTIONS TO CHOOSE FROM BUT
NO DEFAULT (FIRST PARTY)
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 57
Title: iClaim Screens for OMB Clearance Package
9.2.6
APPLICANT HAS MULTIPLE MONTH OF ELECTION OPTIONS TO CHOOSE FROM BUT
NO DEFAULT (THIRD PARTY)
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 58
Title: iClaim Screens for OMB Clearance Package
9.2.7
APPLICANT HAS NOT COMPLETED THE NECESSARY PAGES FOR THEIR MONTH OF
ELECTION OPTIONS TO BE DETERMINED (FIRST PARTY)
9.2.8
APPLICANT HAS NOT COMPLETED THE NECESSARY PAGES FOR THEIR MONTH OF
ELECTION OPTIONS TO BE DETERMINED (THIRD PARTY)
9.2.9
MONTH OF ELECTION SERVICE IS TEMPORARILY UNAVAILABLE (FIRST PARTY)
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 59
Title: iClaim Screens for OMB Clearance Package
9.2.10 MONTH OF ELECTION SERVICE IS TEMPORARILY UNAVAILABLE (THIRD PARTY)
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
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Title: iClaim Screens for OMB Clearance Package
9.3
9.3.1
DIRECT DEPOSIT
FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 61
Title: iClaim Screens for OMB Clearance Package
9.3.2
THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 62
Title: iClaim Screens for OMB Clearance Package
10.0 OTHER BENEFITS: BENEFIT INFO
10.1 RETIREMENT/DISABILITY VERSION
10.1.1 BENEFIT INFORMATION (FIRST PARTY)
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 63
Title: iClaim Screens for OMB Clearance Package
10.1.2 BENEFIT INFORMATION (THIRD PARTY)
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 64
Title: iClaim Screens for OMB Clearance Package
10.1.3 HEALTH INSURANCE (FIRST PARTY)
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 65
Title: iClaim Screens for OMB Clearance Package
10.1.4 HEALTH INSURANCE (THIRD PARTY)
10.2 MEDICARE ONLY VERSION
10.2.1 HEALTH INSURANCE INFORMATION (FIRST PARTY)
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 66
Title: iClaim Screens for OMB Clearance Package
10.2.2 HEALTH INSURANCE INFORMATION (THIRD PARTY)
10.2.3 MEDICAID INFORMATION (FIRST PARTY)
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
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Title: iClaim Screens for OMB Clearance Package
10.2.4 MEDICAID INFORMATION (THIRD PARTY)
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 68
Title: iClaim Screens for OMB Clearance Package
10.2.5 GROUP HEALTH PLAN INFORMATION (FIRST PARTY)
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 69
Title: iClaim Screens for OMB Clearance Package
10.2.6 GROUP HEALTH PLAN INFORMATION (THIRD PARTY)
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 70
Title: iClaim Screens for OMB Clearance Package
11.0 OTHER BENEFITS: DISABILITY QUESTIONS (DISABILITY
ONLY)
11.1 ABILITY TO WORK
11.1.1 FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 71
Title: iClaim Screens for OMB Clearance Package
11.1.2 THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
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Title: iClaim Screens for OMB Clearance Package
11.2 DISABILITY PAYMENTS
11.2.1 FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 73
Title: iClaim Screens for OMB Clearance Package
11.2.2 THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
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Title: iClaim Screens for OMB Clearance Package
11.3 DEPENDENTS
11.3.1 FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
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Title: iClaim Screens for OMB Clearance Package
11.3.2 THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 76
Title: iClaim Screens for OMB Clearance Package
11.4 AUTHORIZATION
11.4.1 FIRST PARTY
11.4.2 THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
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Title: iClaim Screens for OMB Clearance Package
12.0 REMARKS
12.1 RETIREMENT/DISABILITY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 78
Title: iClaim Screens for OMB Clearance Package
12.2 MEDICARE ONLY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 79
Title: iClaim Screens for OMB Clearance Package
13.0 REVIEW: OVERALL SUMMARY
13.1 RETIREMENT VERSION
13.1.1 FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 80
Title: iClaim Screens for OMB Clearance Package
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 81
Title: iClaim Screens for OMB Clearance Package
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
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Title: iClaim Screens for OMB Clearance Package
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
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Title: iClaim Screens for OMB Clearance Package
13.1.2 THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
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Title: iClaim Screens for OMB Clearance Package
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
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Title: iClaim Screens for OMB Clearance Package
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
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Title: iClaim Screens for OMB Clearance Package
13.2 DISABILITY VERSION
13.2.1 FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
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Title: iClaim Screens for OMB Clearance Package
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
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Title: iClaim Screens for OMB Clearance Package
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
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Title: iClaim Screens for OMB Clearance Package
13.2.2 THIRD PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 90
Title: iClaim Screens for OMB Clearance Package
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
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Title: iClaim Screens for OMB Clearance Package
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
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Title: iClaim Screens for OMB Clearance Package
13.3 MEDICARE ONLY VERSION
13.3.1 FIRST PARTY
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
Page 93
Title: iClaim Screens for OMB Clearance Package
Prepared by: OSES/DBSD
Last Updated: August 12, 2010
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Title: iClaim Screens for OMB Clearance Package
13.3.2 THIRD PARTY
Prepared by: OSES/DBSD
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14.0 SUBMIT: SEND THIS APPLICATION
14.1 RETIREMENT VERSION
14.1.1 FIRST PARTY
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14.1.2 THIRD PARTY
14.2 DISABILITY VERSION
14.2.1 FIRST PARTY
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14.2.2 THIRD PARTY
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14.3 MEDICARE ONLY VERSION
14.3.1 FIRST PARTY
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14.3.2 THIRD PARTY
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15.0 NEXT STEPS: RECEIPT SECTION
15.1 RETIREMENT ONLY, FIRST PARTY
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15.2 RETIREMENT ONLY, THIRD PARTY
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15.3 RETIREMENT ONLY, CURRENT MARRIAGE
EVIDENCE REQUIRED, FIRST PARTY
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AND
NO
OTHER
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15.4 RETIREMENT ONLY, CURRENT MARRIAGE
EVIDENCE REQUIRED, THIRD PARTY
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AND
NO
OTHER
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15.5 RETIREMENT ONLY, NO EVIDENCE REQUIRED, FIRST PARTY
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15.6 RETIREMENT ONLY, NO EVIDENCE REQUIRED, THIRD PARTY
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15.7 DISABILITY ALLEGED, FIRST PARTY
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\
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15.8 DISABILITY ALLEGED, THIRD PARTY
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15.9 MEDICARE ONLY, FIRST PARTY (EVIDENCE REQUIRED)
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15.10 MEDICARE ONLY, THIRD PARTY (EVIDENCE REQUIRED)
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15.11 MEDICARE ONLY, NO EVIDENCE REQUIRED, FIRST PARTY
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15.12 MEDICARE ONLY, NO EVIDENCE REQUIRED, THIRD PARTY
16.0 NEXT STEPS: WHAT’S NEXT SECTION
16.1
RETIREMENT ONLY (NO DISABILITY ALLEGED), FIRST PARTY
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16.2 RETIREMENT ONLY (NO DISABILITY ALLEGED), THIRD PARTY
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16.3 DISABILITY ALLEGED W/ LINK TO 3368 REQUIRED, FIRST PARTY
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16.4 DISABILITY ALLEGED W/ LINK TO 3368 REQUIRED, THIRD PARTY
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16.5 DISABILITY ALLEGED BUT NOT CONTINUING TO 3368, FIRST PARTY
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16.6 DISABILITY ALLEGED BUT NOT CONTINUING TO 3368, THIRD PARTY
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16.7 MEDICARE ONLY, FIRST PARTY
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16.8 MEDICARE ONLY, THIRD PARTY
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17.0 MESSAGE PAGES
MSG005
MSG006
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MSG010
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MSG025
MSG028
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MSG029
MSG045
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MSG047
MSG111
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MSG112
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MSG113
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MSG152
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MSG153
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| File Type | application/pdf |
| Author | 500267 |
| File Modified | 2013-08-06 |
| File Created | 2010-08-12 |