Claim For Life Benefit Payment Form printable pdf download

Claim For Life Benefit Payment

Mail To: FAMLI

Claims Department

Financial American Life Insurance Company

14000 SW 119th Avenue

Miami, FL 33186

A Member of the Cardif Group

Phone: 1-877-522-7343

IMPORTANT REMINDER – A payment history from the Creditor, a Certified Copy of the Death Certificate and the Insurance

Certificate Home Office Refund Receipt must accompany this form. If not, processing of benefits will be delayed.

We will not accept a photocopy or fax copy of this form

SECTION A - TO BE COMPLETED BY THE CREDITOR (Please Print)

Claimant Name ______________________________________________________ Acct. No. _____________________ Certificate No. ___________________

Street Address ________________________________________________________________ City ____________________ State ________ Zip __________

Initial Amount of Life Insurance

$ _________________________

(+)

(-)

Less Total Amount Paid on Account

$ _________________________

(as of date od death)

(-)

Less Total Delinquency Charges and/or Other Charges

$ _________________________

(as of date od death)

Balance Due Creditor

$ _________________________

(as of date od death)

Creditor Name ________________________________________________________________________ Telephone Number (

) ____________________

Street Address ________________________________________________________________ City ____________________ State ________ Zip __________

I certify that the information given above is true and correct to the best of my knowledge and belief.

______/______/______

Name/Title of Authorized Creditor Representative (Please Print)

Signature of Authorized Creditor Representative

Date

SECTION B - TO BE COMPLETED BY SURVIVING SPOUSE OR EXECUTOR (Please Print)

Name of Spouse or Executor (if any) ________________________ _______________________________ Telephone Number (

) ____________________

Street Address ________________________________________________________________ City ____________________ State ________ Zip __________

Attach copy of court order naming Executor. If an autopsy was performed, please attach a copy of the report.

Provide complete names and addresses of all treating physicians, including family physician, hospital and pharmacies of the decedent within the past

five (5) years: (attach a separate sheet if necessary).

Name

Street

City

State

Zip

Physician: _______________________________________________________________________________________________________________________

Hospital: ________________ ________________ _________________________________________________________________________________________

Pharmacy: ______________________ _________________________________________________________________________________________________

Street Address ________________________________________________________________ City ____________________ State ________ Zip __________

SPECIAL NOTICE - Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an

application for insurance is guilty of a crime and may be subject to fines or confinement in prison.

FOR OHIO ONLY - Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim

containing a false or deceptive statement is guilty of insurance fraud.

AUTHORIZATION TO RELEASE MEDICAL AND EMPLOYMENT INFORMATION

I certify that the statements contained herein are true and correct to the best of my knowledge and belief and I authorize any health care provider of any medical professional, hospital, or

other medical care institution, the Veteran’s Administration, the Medical Information Bureau, Inc., pharmacy, government agency, insurance company, or employer to provide Financial

American Life Insurance Company or any agent, attorney, consumer reporting agency, or independent administrator, acting on its behalf, information concerning advice, care or treatment

provided to the patient, employee or deceased named above, including information relating to mental illness, communicable disease and infection information, use of drugs and/or alcohol.

The Company, its reinsurers, insurance support organizations and their authorized representatives, may obtain medical and other information in order to determine eligibility for benefits

under an existing policy. I also authorize the employer of the deceased to provide Financial American Life Insurance Company with financial or employment related information. A copy of

this form will be as valid as the original. I understand that such information will be used by Financial American Life Insurance Company for the purpose of evaluating this claim for insurance

benefits and that I or any authorized representative will receive a copy of this Authorization upon request. I also understand that I may revoke this authorization at any time by requesting

such of Financial American Life Insurance Company in writing. This authorization is valid from the date signed for the duration of the claim. The above statements are true and

complete to the best of my knowledge and belief.

Signature is required for benefit consideration.

______/______/______

Signature (Surviving Spouse or Executor)

Date

LCLM.2 (4/06)