1770-250 CH-22, 13 Feb 2008 Page 1 of 4 MILPERSMAN 1770-250 REPORTING DEATH OF NAVAL DEPENDENTS AND SUBMISSION OF FAMILY SERVICEMEMBERS’ GROUP LIFE INSURANCE (FSGLI) CLAIM Responsible CNO Phone: DSN 882-2501 Office (N135C) TOLL FREE WITHIN U.S. (800) 368-3202 COMM (901) 874-2501 FAX (901) 874-2265 References (a) P.L. 107-14, 5 Jun 01 (b) NAVADMIN 281/01 (c) NAVADMIN 317/02 Forms 1. NAVPERS 1070-602 (07-72), Dependency Application/Record of Emergency Data 2. SGLV-8283A (9-07), Claim for Family Coverage Death Benefits 1. Purpose. This article provides procedures for reporting the death of a servicemember’s dependent and submission of a claim when covered by Family Servicemembers' Group Life Insurance (FSGLI) (see references (a), (b), and (c); and MILPERSMAN 1741-020). 2. Reporting Requirement for Dependents. The Active Duty or Navy Reserve member's commanding officer (CO) is responsible for submitting a casualty report. The report should be submitted via E-Mail to MILL_NavyCasualty@navy.mil. The message should indicate the servicemember’s name, rank, and social security number (SSN) (XXX-XX-1234, last four digits) in the subject line. 3. Initial Reporting of Dependent Deaths. The message should contain the following information: a. Dependent’s name/SSN (XXX-XX-1234, last four digits)/relationship to servicemember. 1770-250 CH-22, 13 Feb 2008 Page 2 of 4 b. Command representative assisting the servicemember: name/rank/phone/facsimile (fax)/E-Mail. c. Specify “Dependent Death.” d. Specify date of death/place/circumstances. e. Location of remains. f. Specify if the deceased dependent was insured under the FSGLI program. If the deceased dependent was a spouse, specify the amount of Servicemembers’ Group Life Insurance (SGLI) coverage the servicemember maintained. If unknown, so state. g. Date/time servicemember was notified of dependent's death. h. Any remarks required or desired by command. 4. Example Format for Naval Dependent Death Personnel Casualty Report (PCR). (Use proper message format.) FM PERSUPPACTLANT NORFOLK VA//N00// TO COMNAVPERSCOM MILLINGTON TN//PERS62// INFO CNI WASHINGTON DC//JJJ// PERSUPP DET NEW LONDON CT UNCLASS//N01770// MSGID/GENADMIN/PERSUPPACTLANT NORFOLK VA// SUBJ/REPORT OF DEPENDENT DEATH ICO CT1(AW) MACINERNV, SCOTT M. USN, XXX-XX-1234// REF/A/DOC/MILPERSMAN ARTICLE 1770-250/__ ___ 08)// AMPN/REF A IS REPORTING DEATH OF NAVAL DEPENDENTS AND SUBMISSION OF FAMILY SERVICEMEMBERS’ GROUP LIFE INSURANCE (FSGLI) CLAIM// RMKS/1. FOLLOWING INFO SUBMITTED PER REF A: A. DEPENDENT INFO: MACINERNV, MICHELLE, XXX-XX-5678, DAUGHTER, DOB 1988JUL08. B. POC: CTC (SW/AW) PAUL IKERMAN, WORK (518) 583-1901 CELL (518) 322-6447 FAX (518) 583-1029, EMAIL: PAUL.IKERMAN@NAVY.MIL. C. DEPENDENT DEATH. D. DATE OF DEATH: 10 MAY 2007. PLACE OF DEATH: 2B DOLPHIN TERRACE JACKSON SPRINGS, NV 12866. CIRCUMSTANCES: AT APPROX 0001, 10 MAY 2007, FAMILY MEMBER WAS INVOLVED IN A FATAL TRAFFIC ACCIDENT. E. LOCATION OF REMAINS: JACKSON HOSPITAL, JACKSON SPRINGS NV 12866. F. FSGLI: DEPENDENT IS INSURED UNDER FSGLI. G. MEMBER NOTIFIED 10 MAY 08 1800. H. ADDITIONAL REMARKS. 5. Required Documentation in Dependent Death Cases. The following items are required for FSGLI claims processing: 1770-250 CH-22, 13 Feb 2008 Page 3 of 4 a. SGLV-8283A: Must be completed and signed by the servicemember. This form may be obtained online at http://www.npc.navy.mil/CommandSupport/CasualtyAssistance/General Info/PERS_62_Forms.htm or www.insurance.va.gov. b. NAVPERS 1070/602: Copy of servicemember’s latest NAVPERS 1070/602 showing dependency. NOTE: In the case of infant death where the child is less than 120 days old, an official State-issued birth certificate is required. c. Death Certificate: Final death certificate specifying cause of death. NOTE: Servicemember’s branch of service is required to rule out beneficiary involvement in wrongful death. If final death certificate is unduly delayed, command point of contact (POC) should contact Chief of Naval Operations (CNO), Navy Casualty Assistance Division (N135C) to pursue other means by which to rule out beneficiary involvement. d. For Spousal Deaths: In the case of spousal deaths, the servicemember’s Leave and Earning Statement will be required to show proof of premium payments. e. For Child 18 Years of Age or Older: In the case of a child 18 years of age or older, evidence that (1) the child was, before attaining age 18, declared permanently incapable of self-support; or (2) evidence stating the child was 22 or below and actively pursuing a course of instruction at an approved educational institution. Acceptable evidence is a death certificate listing “student” in the occupation block or a letter from the education institution, on their letterhead, that the child was enrolled. 1770-250 CH-22, 13 Feb 2008 Page 4 of 4 6. Claim Processing in Dependent Death Cases. Applicable items should be transmitted by fax to: CNO, Navy Casualty Assistance Division (N135C) COMM (901) 874-2265, DSN 882-2265 Upon receipt of all applicable items, CNO (N135C) will certify, validate, and forward required documentation to the Office of Servicemembers' Group Life Insurance (OSGLI) for final determination of eligibility and payment. 7. Dependent Child Death of Dual Military Parents/Stepparents. Per reference (a), coverage is available only to one member. Payments under this paragraph are determined on a case-by-case basis. Servicemembers are encouraged to contact CNO (N135C) for additional guidance on claim submission. 8. Beneficiary Involvement. If it is determined by competent authority that the beneficiary was involved in the wrongful death of the insured, payment of claim will be determined by OSGLI on a case-by-case basis.
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