Form 10-Pd - Report Of Death

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P.O. Box 34350 • Omaha, NE 68134-0350
1-800-826-6587 • Fax: 1-800-325-9116
When faxing forms, please
Central States Health & Life Co. of Omaha
follow up with originals by mail.
WARNING: Any person who knowingly fi les a statement of claim containing false, incomplete or misleading information may be subject to crimi-
nal and civil penalties.
REPORT OF DEATH
INSTRUCTIONS:
(1) Creditor complete Report of Death
(2) Submit a certifi ed copy of the Death Certifi cate with this Report of Death.
The furnishing of this form is neither an admission of coverage or liability by the Company nor a waiver of any rights of defenses.
CREDITOR’S STATEMENT
Name of Insured in full _______________________________________________________________________________
Address __________________________________________________________________________________________
LOAN OR CONTRACT INFORMATION
INSURANCE INFORMATION
Date of Note: ___________________________________
Effective Date of Policy/Certifi cate:
Has note been refi nanced since above date? _________
___________________________________
If yes, when? __________________________________
Policy/Certifi cate Number:
Amount of Note: _________________________________
___________________________________
Term of Note: ___________________________________
Original Amount of Life Insurance:
First Payment Due Date: __________________________
___________________________________
Last Payment Due Date: __________________________
Term of Insurance (months):
Amount Paid Prior to Death: _______________________
___________________________________
Date of Last Payment: ____________________________
PAYOFF INFORMATION
Net Pay-Off Balance as of today:
*NOTE: There is no life premium refund given
Credit Life Premium Refund:
+
on a life claim. If your system automatically
debits the life premium when calculating the
EQUALS Total Amount of Pay-Off:
=
payoff amount, please add the premium re-
fund back into the payoff amount.
Interest Charged per day: ___________
Note: This does not apply in SC and WY.
Is Account Delinquent? ____Yes ___ No How long? _______
Amount: __________
I hereby certify that the answers given above are full and true:
Signed:________________________________________________________
Date: ____________________________
Offi cial Position: _________________________________________________
Financial Institution Name: ________________________________________
Address:_______________________________________________________
Phone Number: __________________________________
Loan Account Number: _____________________________
*NOTE: Be sure that you have complied with applicable State Laws in computing Net Pay-Off Balance. If policy provides for a Second Benefi ciary
participation in death proceeds, the benefi ts in excess of amount paid Creditor will be allowed according to Insurance Statutes.
Form 10 PD 15th Rev.
9-09

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