Statement Of Claimant To Be Completed For Life And/or Annuity Benefits Form printable pdf download

Life & Annuity Department

P.O. Box 25160

Oklahoma City, Ok. 73125

S T A T E M E N T O F C L A I M A N T

Telephone #1-800-662-1113

Local 523-5025, ext. 7130

TO BE COMPLETED FOR LIFE AND/OR ANNUITY BENEFITS

In furnishing this form, the Company reserves all of its rights under the Policy and waives none of the conditions of the Policy.

PART I

INSURED'S IDENTIFICATION

Account No. _____________________________________ Social Security No __________________________

Insured's name in full__________________________________________Also known as: __________________

Address____________________________________________ City ___________________ State ___________

Date of Birth_______________________________________Date of Death _____________________________

Occupation ___________________________________________________Date Last Worked ______________

Employer ________________________________ Address __________________________________________

PART II

DEPENDENT IDENTIFICATION

If claim is on a dependent:

Name of Deceased ______________________________ Relationship to Insured __________________________

Address: _________________________________________City____________________State_______________

Date of Birth:______________ Social Security No. _______________________Date of Death_______________

Employer___________________________________________________________________________________

Address:____________________________________________________________________________________

Occupation _______________________________________ Date last Worked: ___________________________

PART III

CLAIMANT'S IDENTIFICATION

Your Name _________________________________________ Relationship to Deceased __________________

Social Security # ___________________Telephone # ___________________Date of Birth_________________

Address ___________________________________ City ________________________State ________________

Do you claim this insurance as K Beneficiary K Executor K Guardian K Other capacity

If Executor or Administrator, attach Letters Testamentary or Letters of Administration.

PART IV

MEDICAL INFORMATION

Date Deceased first consulted a physician for his last illness ____________________________________________

Names and addresses of all physicians who treated the deceased and of all hospitals or institutions where the

insured was treated during the last five years: (Attach additional pages if needed)

Name of Physician or Hospital

Address

Dates Treated

Conditions

__________________________________________________________________________________________

PART V

ACCIDENTS (Complete only if loss is the result of accidental injury)

Where did the accident happen? ___________________________________ Date of Accident ______________

How did the accident happen? _________________________________________________________________

K YES K NO

Was the injury received in the course of employment?

PART VI

CERTIFICATION

I certify the above statements are true and complete to the best of my knowledge.

Warning: Any person who knowingly, and with intent to injure, defraud, or deceive any insurer files a statement of claim containing

any false, incomplete, or misleading information may be guilty of insurance fraud and subject to criminal and civil penalties.

Signed __________________________________________________________________ Date: ______________________

(Claimant/Beneficiary)

Please complete and sign the authorization on the reverse of this form.

BN-151(0605)

Statement Of Claimant To Be Completed For Life And/or Annuity Benefits Form

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