Statement Of Claimant 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 q beneficiary q executor q Guardian q 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? _________________________________________________________________

Was the injury received in the course of employment?

q yeS q no

part Vi

CertifiCation

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

Warning: for your protection, arizona law requires the following statement to appear on this form: any person who

knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

Signed __________________________________________________________________ date: ______________________

(Claimant/beneficiary)

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

bn-151(aZ)-0806

Statement Of Claimant For Life And/or Annuity Benefits Form

Related Articles

Related forms

Related Categories