Form Gn-65687-Hh - Humana Group Life Claim Form - Rogers Benefit Group Page 3
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4Humana Insurance Company
Group Life Claims
P.O. Box 10708
Part two—beneficiary statement
Green Bay, WI 54307-0708
1-866-836-6144
To be completed by beneficiary
If the beneficiary is a minor, please provide Letters of Guardianship for the minor’s estate.
If the beneficiary is the estate, please provide the Letters Testamentary or Letters of Administration appointing the personal
representative of the estate.
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.
Beneficiary information
Name of beneficiary
Date of birth
Social Security Number/Tax ID number
Phone number
Address of beneficiary
City
State
Zip
Relationship to deceased
Signature of beneficiary: ____________________________________________________________________ Date ______________________
Name of beneficiary
Date of birth
Social Security Number/Tax ID number
Phone number
Address of beneficiary
City
State
Zip
Relationship to deceased
Signature of beneficiary: ____________________________________________________________________ Date ______________________
Name of beneficiary
Date of birth
Social Security Number/Tax ID number
Phone number
Address of beneficiary
City
State
Zip
Relationship to deceased
Signature of beneficiary: ____________________________________________________________________ Date ______________________
Name of beneficiary
Date of birth
Social Security Number/Tax ID number
Phone number
Address of beneficiary
City
State
Zip
Relationship to deceased
Signature of beneficiary: ____________________________________________________________________ Date ______________________
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GN-65687-HH 12/04
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