Form Gn-65687-Hh - Humana Group Life Claim Form - Rogers Benefit Group printable pdf download

Form Gn-65687-Hh - Humana Group Life Claim Form - Rogers Benefit Group

Humana Insurance Company

Group Life Claims

P.O. Box 10708

Humana group life claim form

Green Bay, WI 54307-0708

1-866-836-6144

Instructions

Please submit the following documentation:

1. Group life claim form.

• Part one—completed by the employer

• Part two—completed by the beneficiary

2. The original enrollment form or photocopy and any beneficiary changes.

3. A certified copy of the official death certificate.

4. For accidental death benefits, we require the official complete police report and

any coroner’s report including laboratory findings if an autopsy was conducted.

5. If the beneficiary is:

• A minor—we require copies of the guardianship papers naming the legal guardian of the minor’s estate.

• An estate—we require the Letters Testamentary or Letters of Administration appointing the

personal representative of the estate.

• Deceased—we require a copy of the deceased beneficiary’s official death certificate.

We may require additional information or documents to process the claim.

Please mail all documentation to:

Humana Insurance Company

Group Life Claims

P.O. Box 10708

Green Bay, WI 54307-0708

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GN-65687-HH 12/04

Form Gn-65687-Hh - Humana Group Life Claim Form - Rogers Benefit Group