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

AWD Benefits department

p.o. box 268898

oklahoma City, oK 73126-8898

S t a t e m e n t o f C l a i m a n t

telephone #1-800-437-1011

Toll Free Fax #1-888-243-3453

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 ___ Zip________

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 ___ Zip_________

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 ___ Zip________

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: any person who knowingly and with intent to defraud any insurance company or other person files an

application for insurance or statement of claim containing any materially false information or conceals for the purpose

of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and

subjects such person to criminal and civil penalties.

Signed __________________________________________________________________ date: ______________________

(Claimant/beneficiary)

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

bn-151(AWD)(pa)-0609

Statement Of Claimant For Life And/or Annuity Benefits Form

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