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Report a death

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Enter Policy Number(s):

To better help us assist you, please enter your policy number and press Check Policy (s) below. If you don't have a policy number, please fill out and submit the remainder of the form.

Policy #1:
Policy #2:
Policy #3:
Deceased Information:
Last Name of Deceased:
First Name of Deceased:
Social Security Number: - -
Date of Death (MM/DD/YYYY): - -
Date of Birth (MM/DD/YYYY): - -
Cause of Death: Disease Homicide
Suicide Natural
Accident Unknown
Are you the Beneficiary?: Yes No Not Sure
Contact Information:

A claim form will be sent to you only if you are the beneficiary or the beneficiary's authorized representative (such as an attorney or as a guardian for a minor). A letter is required from an authorized representative stating that he/she is representing the beneficiary.

If you are not the beneficiary or beneficiary's authorized representative, please be assured that we will search our policy records. In the event that the deceased insured had a policy with us, we will begin the claim process and contact the beneficiary listed on our policy records.

Your Last Name:
Your First Name:
Street Address 1:
Street Address 2:
City:
State:
ZIP Code: -
Country:
Daytime Telephone Number: - -
ext.
ZIP Code:
Country:
Daytime Telephone Number:
E-mail Address:
Relationship of Contact to Deceased: Spouse Sibling
Parent Attorney
Child Other
Agent
Will you be providing the claim forms to the beneficiary? Yes No
Will you be delivering the proceeds to the beneficiary? Yes No
Beneficiary Information:

If you are the beneficiary, providing the information below may help expedite the processing of the claim.

Beneficiary Social Security Number: - -
Beneficiary Date of Birth (MM/DD/YYYY): / /
Funeral Home Name:
Funeral Home Address 1:
Funeral Home Address 2:
Funeral Home City:
Funeral Home State:
Funeral Home Zip Code: -
Funeral Home Country:
Funeral Home Telephone Number: - -
ext.
Funeral Home ZIP Code:
Funeral Home Country:
Funeral Home Telephone Number:
Question / Comment

Please enter your comments and/or questions in the space provided.


As an additional security measure, please enter the words you see below into the Your Answer field, and then press the Submit button.



Policy #1:

Unfortunately we are unable to assist you regarding your request.
Please contact the following office for assistance.

 
 
 
 

 

 
Policy #2:

Unfortunately we are unable to assist you regarding your request.
Please contact the following office for assistance.

 
 
 
 

 

 
Policy #3:

Unfortunately we are unable to assist you regarding your request.
Please contact the following office for assistance.