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Effective Date: 
5/2016

Documents


Instructions

Updated: 6/2002

Purpose

To request information about an applicant/recipient's insurance policies.

Procedure

When to Prepare

The worker sends Form H1238 to insurance companies to get pertinent information about insurance policies.

Number of Copies

The worker completes an original, typed or legibly handwritten. He records the date he sent the form on Form H0007-A, Financial Services Activity Record, or prepares a copy of Form H1238 for the case record. (Follow regional instructions.)

Transmittal

The worker sends the original to the appropriate insurance company and keeps the duplicate (if any) in the case record. Attach Form H0003, Authorization To Furnish Information (signed by the applicant, recipient, or responsible person), to the original.

Form Retention

If a copy is made for the case record, keep the copy for three years.

Detailed Instructions

To — Enter the name and address of the insurance company.

From — Enter the worker's name and local office mailing address.

ApplicantIRecipient Information — Enter the name of the insured, the insurance policy number(s), if known, and any pertinent comments.

The worker signs the form and enters the date and his telephone number. An insurance company representative completes the other items on the form.