Form Gn-65687-Hh - Humana Group Life Claim Form - Rogers Benefit Group Page 2
ADVERTISEMENT
1
2
3
4Humana Insurance Company
Group Life Claims
P.O. Box 10708
Part one—employer statement
Green Bay, WI 54307-0708
1-866-836-6144
To be completed by employer
Employment information
Name of employer
Group number
Address of employer
City
State
Zip
Name of employee/retiree
Date of birth of employee/retiree
Address of employee/retiree
City
State
Zip
Job title
Original date of employment
Date employee last worked full-time hours
Reason employee stopped work (if more than 31 days)
Annual base salary $
Hours worked per week
Date of last salary payment to employee
Amount paid
Deceased information
Deceased is:
Employee
Retiree
Spouse
Child
Name of deceased, if spouse or child
Member identification number
Other names by which the decedent may have been known (e.g. maiden name, hyphenated name or an alias)
Address of deceased, if spouse or child
City
State
Zip
Date of birth
Date of death
Effective date of insurance
Does the deceased have any other life insurance coverage with Humana, Inc., its subsidiaries or affiliates?
Yes
No
Are Accidental Death Benefits being claimed?
Yes
No
If yes, please submit copies of the police report and the coroner’s report (including laboratory findings) if an autopsy was conducted.
Self administered employer groups—please complete this section
Insurance class:
Amount of basic life insurance $
Amount of Accidental Death Benefit $
Amount of optional (voluntary) insurance $
Date of last increase in insurance
Signature (all groups)
I certify that I have read this document and the information is accurate and complete. I understand that any person who knowingly files a
statement of claim containing any false or misleading information is subject to criminal and civil penalties.
Authorized signature of employer: ____________________________________________________________ Date ______________________
2 of 4
GN-65687-HH 12/04
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business