Form Gc-1373 (11-13) - Aenta Proof Of Death
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1
2
3Proof of Death
Please fax or mail this claim to:
Aetna Life Insurance Company
PO Box 14549
Group Life Insurance and Group Accidental Death Benefit
Lexington, KY 40512-4549
Request
FAX: 1-800-238-6239
(Filing instructions on reverse side)
A. Information About the Deceased
Deceased's Name (Last, First, Middle Initial)
If deceased is known by any other name, provide Name (Last, First, Middle Initial)
Relationship to Employee
Social Security Number
Birthdate (MM/DD/YYYY)
Date of Death (MM/DD/YYYY)
Age
Gender
Male
Female
Last Residence: Street
City
State
ZIP
B. Information About the Employee
Employee's Name (Last, First, Middle Initial)
Social Security Number
Birthdate (MM/DD/YYYY)
Last Residence: Street
City
State
ZIP
Date Employed (MM/DD/YYYY)
Work Location Name/Number
Occupation/Class
Hourly
Salary
Date Last Worked (MM/DD/YYYY)
Reason employee did not return to work after last day worked.
C. Information About the Employee's Coverage
Employer's Name
Representative's / Contact's Name / Email Address
Street Address
City
State
ZIP
Telephone Number
Was an Accelerated Death Benefit, Accidental Dismemberment or Enhancement benefit such as Coma, Traumatic Brain Injury, Surgical
Reattachment, Third Degree Burn, Children’s Double Indemnity Benefit claim submitted prior to death?
No
Yes
Fax Number
Was waiver of premium claim submitted prior to death?
No
Yes
Coverages for which benefits are in effect and being claimed
Effective date of
employee's insurance
Amount of insurance in force
Group Coverage
Control
Suffix
Account
Plan
(MM/DD/YYYY)
as of the date last worked
Basic Life
/
/
/
/
Supplemental Life
/
/
/
/
Dependent Life
/
/
Accidental Death
/
/
Group Accident
/
/
Paid-up Life
/
/
Group Universal Life
/
/
/
/
If insurance is based on earnings, basic rate of earnings on date last worked or frozen salary.
$
per
Hour
Week, give number of hours worked per week
Month
Year
If insurance is based on other earnings, identify type
Date of Last Salary Increase (MM/DD/YYYY)
Has amount of insurance increased (other than salary) within the last two years?
(i.e., commission, bonus, etc.) and amount.
No
Yes
Type
$
If Yes, give date
(MM/DD/YYYY)
Did the insured change his contributory coverage elections on the Aetna plan effective date?
No
Yes
Was employee required to submit evidence of insurability to
Were premiums paid through the date of death
If insurance is not in effect, give date discontinued (MM/DD/YYYY)
secure current coverage?
for this insured?
No
Yes
No
Yes
Has the deceased converted his group insurance?
Did the deceased have an Aetna long term care policy?
No
Yes
If Yes, give Policy Number
No
Yes
If Yes, give Policy Number
GC-1373 (11-13) P
R-POD
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