Basic (05-11)
   
   
   
   
      INS001 MEDICAL INSURANCE BENEFICARY (BIC M) - NO HOSPITAL OR FULLY INSURED STATUS (Q03)
      
      
      (Requested)
      
      Caption: Your Benefits
      
       (1)  not worked long enough under Social Security to receive monthly benefits or premium
         free hospital insurance under Medicare.
      
      
      Work under Social Security is figured in credits. Please read the enclosed pamphlet,
         “How You Earn Social Security Credits”, which explains how the credits are earned
         and how many a person needs to receive benefits.
      
      
      To qualify for monthly benefits  (2)  a total of  (3)  work credits. For hospital insurance,  (4)   (5)  credits.  (6)  earned  (7)  credits.
      
      
       (8)  may earn the additional credits  (9)  by working under Social Security. If  (10)  the credits,  (11)  should get in touch with us to apply again.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: You have
            Choice 2: Beneficiary's Name has
         Fill-in (2) - Systems Generated
            
            
Choice 1: you need
            Choice 2: he needs
            Choice 3: she needs
         Fill-in (3) – Requested As A Number
            
            
Choice 1: Number of quarters for insured status
         Fill-in (4) - Systems Generated
            
            
Choice 1: you need
            Choice 2: he needs
            Choice 3: she needs
         Fill-in (5) – Requested As A Number
            
            
Choice 1: Number of quarters for HI coverage
         Fill-in (6) - Systems Generated
            
            
Choice 1: You have
            Choice 2: He has
            Choice 3: She has
         Fill-in (7) – Requested As A Number
            
            
Choice 1: Number of acquired quarters
         Fill-in (8) - Systems Generated
            
            
Choice 1: You
            Choice 2: He
            Choice 3: She
         Fill-in (9) - Systems Generated
            
            
Choice 1: you need
            Choice 2: he needs
            Choice 3: she needs
         Fill-in (10) - Systems Generated
            
            
Choice 1: you earn
            Choice 2: he earns
            Choice 3: she earns
         Fill-in (11) - Systems Generated
            
            
Choice 1: you
            Choice 2: he
            Choice 3: she
          
    
   
      INS002 CLAIMANT NEITHER FULLY INSURED NOR INSURED FOR HI (Q06)
      
      
      (Requested)
      
      Caption: Your Benefits
      
      Neither monthly benefits nor premium–free Hospital Insurance benefits are payable
         at this time because  (1)  not worked long enough under Social Security. To qualify for monthly benefits,  (2)  credit for  (3)  calendar quarters of work. For Hospital Insurance benefits  (4)   (5)  quarters. Our records show that  (6)   (7)  . The enclosed leaflet explains how a person earns Social Security work credits.
         If  (8)  the additional quarters, please contact any Social Security office promptly.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: you have
            Choice 2: Beneficiary's Name has
         Fill-in (2) - Systems Generated
            
            
Choice 1: you need
            Choice 2: he needs
            Choice 3: she needs
         Fill-in (3) – Requested As A Number
            
            
Choice 1: Number of required quarters for fully insured status
         Fill-in (4) - Systems Generated
            
            
Choice 1: you need
            Choice 2: he needs
            Choice 3: she needs
         Fill-in (5) – Requested As A Number
            
            
Choice 1: Number of required quarters for HI status
         Fill-in (6) - Systems Generated
            
            
Choice 1: you now have
            Choice 2: he now has
            Choice 3: she now has
         Fill-in (7) - Requested As A Number
            
            
Choice 1: Number of acquired quarters
         Fill-in (8) - Systems Generated
            
            
Choice 1: you earn
            Choice 2: he earns
            Choice 3: she earns
          
    
   
      INS003 BENE DOES NOT QUALIFY FOR REGULAR OR TRANSITIONAL BENEFITS - NOT ENOUGH QUARTERS (Q10)
      
      
      (Requested)
      
      Caption: Your Benefits
      
      Benefits are not payable at this time because  (1)  not worked long enough under Social Security. To qualify for regular monthly benefits,
          (2)  credit for  (3)  calendar quarters of work or for transitional monthly benefits  (4)   (5)  quarters. Our records show that  (6)   (7)  . The enclosed leaflet explains how a person earns Social Security work credits.
         If  (8)  the additional quarters and can furnish proof of  (9)  age, please contact any Social Security office promptly.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: you have
            Choice 2: Beneficiary's Name has
         Fill-in (2) - Systems Generated
            
            
Choice 1: you need
            Choice 2: he needs
            Choice 3: she needs
         Fill-in (3) – Requested As A Number
            
            
Choice 1: Number of required quarters for fully insured status
         Fill-in (4) - Systems Generated
            
            
Choice 1: you need
            Choice 2: he needs
            Choice 3: she needs
         Fill-in (5) – Requested As A Number
            
            
Choice 1: Number of quarters required for transitionally insured status
         Fill-in (6) - Systems Generated
            
            
Choice 1: you now have
            Choice 2: he now has
            Choice 3: she now has
         Fill-in (7) – Requested As A Number
            
            
Choice 1: Number of acquired quarters
         Fill-in (8) - Systems Generated
            
            
Choice 1: you earn
            Choice 2: he earns
            Choice 3: she earns
         Fill-in (9) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
          
    
   
      INS004 SURVIVOR BENEFITS NOT PAYABLE - DECEASED DID NOT HAVE ENOUGH QUARTERS (Q14)
      
      
      (Requested)
      
      Caption: Your Benefits
      
      Survivor benefits are not payable on this record because  (1)  did not work long enough under Social Security. To qualify,  (2)  needed credit for either a total of  (3)  calendar quarters of work or at least 6 quarters of work in the 13-quarter period
         ending with death. Since our records show that  (4)  has credit for a total of  (5)  quarters of work and  (6)  in the 13-quarter period, neither of these requirements is met. The enclosed leaflet
         explains how a person earns Social Security work credits.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: your husband
            Choice 2: your former husband
            Choice 3: your father
            Choice 4: your mother
            Choice 5: your wife
         Fill-in (2) - Systems Generated
            
            
Choice 1: he
            Choice 2: she
         Fill-in (3) – Requested As A Number
            
            
Choice 1: Number of quarters for fully insured status
         Fill-in (4) - Systems Generated
            
            
Choice 1: he
            Choice 2: she
         Fill-in (5) – Requested As A Number
            
            
Choice 1: Number of acquired quarters
         Fill-in (6) – Requested As A Number
            
            
Choice 1: Number of acquired quarters in 13-quarter period
          
    
   
      INS005 BENEFITS NOT PAYABLE - DID NOT WORK LONG ENOUGH UNDER U.S. SOCIAL SECURITY SYSTEM
         (Q15)
      
      
      (Requested)
      
      Caption: Your Benefits
      
      Benefits are not payable at this time based on  (1)  work covered by the United States because  (2)  not worked long enough under the United States Social Security system. To qualify
         for  benefits,  (3)  credit for  (4)  calendar quarters of work. Our records show that under the United States Social Security
         system  (5)   (6)  .
      
      
      The enclosed leaflet explains how  (7)  can earn Social Security work credits. If  (8)  the additional quarters of work, please contact any Social Security office right
         away.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: your
            Choice 2: Beneficiary's Name possessive
         Fill-in (2) - Systems Generated
            
            
Choice 1: you have
            Choice 2: he has
            Choice 3: she has
         Fill-in (3) - Systems Generated
            
            
Choice 1: you need
            Choice 2: he needs
            Choice 3: she needs
         Fill-in (4) – Requested As A Number
            
            
Choice 1: Number of required quarters of coverage
         Fill-in (5) - Systems Generated
            
            
Choice 1: you now have
            Choice 2: he now has
            Choice 3: she now has
         Fill-in (6) - Requested As A Number
            
            
Choice 1: Number of acquired quarters of coverage
         Fill-in (7) - Systems Generated
            
            
Choice 1: you
            Choice 2: he
            Choice 3: she
         Fill-in (8) - Systems Generated
            
            
Choice 1: you earn
            Choice 2: he earns
            Choice 3: she earns
          
    
   
      INS006 NH NOT INSURED FOR MEDICARE (Q18)
      
      
      (Requested)
      
      Caption: Your Benefits
      
       (1)  not eligible for Medicare coverage at this time because  (2)  not have enough work credits. To qualify,  (3)  credit for  (4)  calendar quarters of work. Our records show that  (5)   (6)  . Government employees earn Medicare work credits for their Government employment
         in the same way Social Security credits are earned for non-Government employment.
         The enclosed leaflet explains how a person earns Social Security credits. If  (7)  the additional quarters, please contact any Social Security office promptly.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: You are
            Choice 2: Beneficiary's Name is
         Fill-in (2) - Systems Generated
            
            
Choice 1: you do
            Choice 2: he does
            Choice 3: she does
         Fill-in (3) - Systems Generated
            
            
Choice 1: you need
            Choice 2: he needs
            Choice 3: she needs
         Fill-in (4) - Requested As A Number
            
            
Choice 1: Required Government employment QCs
         Fill-in (5) - Systems Generated
            
            
Choice 1: you now have
            Choice 2: he now has
            Choice 3: she now has
         Fill-in 6 - Requested As A Number
            
            
Choice 1: Acquired Government employment QCs
         Fill-in 7 - Systems Generated
            
            
Choice 1: you earn
            Choice 2: he earns
            Choice 3: she earns
          
    
   
      INS007 BENEFITS NOT PAYABLE - NOT ENOUGH QUARTERS TO BE FULLY OR CURRENTLY INSURED (Q17)
      
      
      (Requested)
      
      Caption: Your Benefits
      
      Benefits are not payable on this record because  (1)  did not have enough work under Social Security to be fully or currently insured.
         To be fully insured, a total of  (2)  calendar quarters of work are needed. Our records show that this requirement has
         not been met. To be currently insured, at least 6 calendar quarters of work in the
         13-quarter period ending in death are needed. Our records show that  (3)  has  (4)  . Since neither of these requirements are met, no benefits are payable. The enclosed
         leaflet explains how a person earns Social Security work credits.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: NH's name
         Fill-in (2) - Requested As A Number
            
            
Choice 1: Number of required quarters for fully insured status
         Fill-in (3) - Systems Generated
            
            
Choice 1: he
            Choice 2: she
         Fill-in (4) - Requested As A Number
            
            
Choice 1: Number of acquired quarters of coverage in the 13-quarter period
          
    
   
      INS008 NO BENEFITS PAYABLE - NOT ENOUGH QUARTERS EARNED BASED ON DOB(Q05)
      
      
      (Requested)
      
      Caption: Your Benefits
      
      Benefits are not payable at this time because  (1)  not worked long enough under Social Security. Based on the date of birth  (2)  gave us,  (3)  credit for  (4)  calendar quarters of work. Our records show that  (5)    (6)  . The enclosed leaflet explains how a person earns Social Security work credits.
         If  (7)  the additional quarters and can furnish proof of  (8)  age, please contact any Social Security office promptly.
      
      
      Enclosure: SSA-10072
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: you have
            Choice 2: Beneficiary's Name +has
         Fill-in (2) - Systems Generated
            
            
Choice 1: you
            Choice 2: he
            Choice 3: she
         Fill-in (3) - Systems Generated
            
            
Choice 1: you need
            Choice 2: he needs
            Choice 3: she needs
         Fill-in (4) - Requested As A Number
            
            
Choice 1: Number of quarters required for insured status
         Fill-in (5) - Systems Generated
            
            
Choice 1: you now have
            Choice 2: he now has
            Choice 3: she now has
         Fill-in (6) - Requested As A Number
            
            
Choice 1: Number of acquired quarters
         Fill-in (7) - Systems Generated
            
            
Choice 1: you earn
            Choice 2: he earns
            Choice 3: she earns
         Fill-in (8) - Systems Generated
            
            
Choice 1: your
            Choice 2: his
            Choice 3: her
          
    
   
      INS017 SPOUSE OR CHILD CLAIMANT - NH NOT INSURED FOR MEDICARE BASED ON UNPROVEN DATE OF BIRTH
         (Q22)
      
      
      Caption: Your Benefits
      
      Requested
      
       (1)  not eligible for Medicare coverage at this time because  (2)   does not have enough work credits. Based on the date of birth given us,  (3)   needs credit for  (4)   calendar quarters of work. Our records show that  (5)  has  (6)  calendar quarters.
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: You are
            Choice 2: Beneficiary Name plus is
         Fill-in (2) - Systems Generated
            
            
Choice 1: Number holder name
         Fill-in (3) - Systems Generated
            
            
Choice 1: he
            Choice 2: she
         Fill-in (4) - Requested As A Number
            
            
Choice 1: Required Government employment QCs
         Fill-in (5) - Systems Generated
            
            
Choice 1: Number holder name
         Fill-in (6) - Requested As A Number
            
            
Choice 1: Acquired Government employment QCs
          
    
   
      INS018 NO BENEFITS PAYABLE - NOT ENOUGH QUARTERS EARNED (Q02)
      
      
      (Requested)
      
      Caption: Your Benefits
      
      Benefits are not payable at this time because  (1)  not worked long enough under Social Security. To qualify,  (2)  credit for  (3)  calendar quarters of work. Our records show that  (4)   (5)  . The enclosed leaflet explains how a person earns Social Security work credits.
         If  (6)  the additional quarters, please contact any Social Security office promptly.
      
      
      Enclosure:
      
      SSA-10072
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: you have
            Choice 2: Beneficiary's Name + has
         Fill-in (2) - Systems Generated
            
            
Choice 1: you need
            Choice 2: he needs
            Choice 3: she needs
         Fill-in (3) - Requested As A Number
            
            
Choice 1: Number of required quarters for fully insured status (zero suppressed)
         Fill-in (4) - Systems Generated
            
            
Choice 1: you now have
            Choice 2: he now has
            Choice 3: she now has
         Fill-in (5) - Requested As A Number
            
            
Choice 1: Number of acquired quarters (zero suppressed)
         Fill-in (6) - Systems Generated
            
            
Choice 1: you earn
            Choice 2: he earns
            Choice 3: she earns
          
    
   
      INS021 AUXILIARY CLAIMANT NOT INSURED ON OWN RECORD (C23)
      
      
      (Requested)
      
      Caption: Other Social Security Benefits
      
       (1)   (2)  not worked long enough under Social Security to receive benefits  (3)  .
      
      
      Work under Social Security is figured in credits. Please read the enclosed pamphlet,
         "How You Earn Social Security Credits," which explains how the credits are earned
         and how many a person needs to receive benefits.
      
      
      To qualify for benefits,  (4)   (5)  a total of  (6)  work credits.  (7)   (8)  earned  (9)  credits, and still  (10)   (11)   (12)  more. These figures are based on  (13)   (14)  ,  (15)  .
      
      
      
      Fill-in values:
         
         Fill-in (1) - Systems Generated
            
            
Choice 1: You
            Choice 2: number holder's fullname
         Fill-in (2) - Systems Generated
            
            
Choice 1: have
            Choice 2: has
         Fill-in (3) - Systems Generated
            
            
Choice 1: on your own record
            Choice 2: on his own record
            Choice 3: on her own record
         Fill-in (4) - Systems Generated
            
            
Choice 1: you
            Choice 2: she
            Choice 2: he
         Fill-in (5) - Systems Generated
            
            
Choice 1: need
            Choice 2: needs
         Fill-in (6) – Requested As A Number
            
            
Required QCs
         Fill-in (7) - Systems Generated
            
            
Choice 1: You
            Choice 2: She
            Choice 2: He
         Fill-in (8) - Systems Generated
            
            
Choice 1: has
            Choice 2: have
         Fill-in (9) - Requested As A Number
            
            
earned QCs
         Fill-in (10) - Systems Generated
            
            
Choice 1: need
            Choice 2: needs
         Fill-in (11) – Requested As a Number
            
            
quarters still needed
         Fill-in (12) - Systems Generated
            
            
Choice 1: credit
            Choice 2: credits
         Fill-in (13) - Requested As A One Position Alpha Character
            
            
Choice A: the date of birth
            Choice B: your
            Choice C: Mr plus NH-NAME, possessive
            Choice D: Ms plus NH-NAME, possessive
         Fill-in (14) - Requested As A One Position Alpha Character
            
            
Choice A: NULL
            Choice B: corrected date of birth
            Choice C: date of birth
         Fill-in (15) - Systems Generated
            
            
Choice 1: number holder's date of birth