Employer'S Statement Template
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1Mail completed form to:
Group Claims
THIS DOCUMENT IS
Security Mutual Life Insurance Company of New York
FORM FILLABLE
PO Box 1625 • Binghamton, NY 13902-1625
EMPLOYER’S STATEMENT
GROUP LIFE INSURANCE DEATH CLAIM FORM
TO BE COMPLETED BY THE EMPLOYER
Employee’s name: _________________________________________________________ Policy Number: _____________________________
Address: ___________________________________________________________________________________________________________
Number
Street
City
State
Zip Code
Date of birth: _________________________
Date of Death: ________________________ Social Security Number: __________________
(mm/dd/yyyy)
(mm/dd/yyyy)
Date of Employment: _____________________ Date Lasted Worked: ____________________ Employee’s Occupation:_________________
(mm/dd/yyyy)
(mm/dd/yyyy)
Average number of hours worked per week: ______ Base annual compensation (do not include bonuses, overtime, etc): $______________
Reason for leaving work: q Disability q Lay-off q Dismissed q Resigned q Leave of Absence q Retired
q Other–State reason _________________________________________________________________________
Effective Date of Coverage: ___________________ Certificate Number: ________________ Amount of Insurance $__________________
Classification: ______________________________ Termination Date of Insurance: ______________________________________________
DEPENDENT COVERAGE – Complete if claim is on a covered dependent
Dependent’s Name: _________________________________________________ Dependent’s Date of Birth: __________________________
Relationship to Employee: _____________________________________________________________________________________________
BENEFICIARY INFORMATION – If more than one beneficiary is named, attach a separate sheet with the requested information for each
named beneficiary.
Name of Beneficiary: ___________________________________
Address: ___________________________________________________________________________________________________________
Number
Street
City
State
Zip Code
Beneficiary’s Relationship to Deceased: __________________________ Beneficiary’s Date of Birth: ________________________________
(mm/dd/yyyy)
It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits.
Date Signed: ___________________________
Employer’s name: ____________________________________________________________________________________________________
Complete business address: ___________________________________________________________________________________________
Number Street
City
State
Zip Code
Signature of person completing this form: ________________________________________________________________________________
Print name and title of person completing this form: _______________________________________________________________________
Employer’s Telephone Number: ____________________________ Employer’s Fax Number: ______________________________________
Email address: ______________________________________________________________________________________________________
For assistance in completing this form, please call the Group Claims unit at 1-800-382-6400.
0012499XX 02/2010
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Parent category: Business