Life Insurance

Report a Death Claim Form

*=Required

Please use this form to report Individual Life Insurance Policy claims only.

If the policy you are reporting is not a death claim for an Individual Life Insurance Policy, please refer to the other policy options on the Individual Claims page.

Life Insurance Policy Number

Your Information

First Name

Middle Name

Last Name

Phone

Mailing Address

City

State

Zip Code

Email Address

How would you prefer that we communicate with you?

Mail

Are you aware of any other parties/beneficiaries to this claim? If so, please provide their names and contact information

Deceased Information

Deceased First Name

Deceased Last Name

Deceased Date of Birth

Please enter date format as: MM/DD/YYYY

Date of Death

Please enter date format as: MM/DD/YYYY

If Manner of Death is Natural, please provide a more specific cause of death (for example, heart attack, lung cancer, etc.)

Did the death occur in the United States, Canada or a U.S. territory (Puerto Rico, Guam, American Samoa, U.S. Virgin Islands)?

Yes

Funeral Home Information

Funeral Home Name

Funeral Home Address

Funeral Home Phone Number

Comments

Other Comments

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HIPAA Notification

Life Insurance Report a Death Claim Form