Fillable Form C-5082 - Proofs Of Death-Claimant'S Statement printable pdf download

PROOFS OF DEATH-CLAIMANT'S STATEMENT

INSURING COMPANY (Please check one):

American-Amicable Life Insurance Company of Texas • Email:

IA American Life Insurance Company • Email:

Industrial Alliance Insurance and Financial Services Inc. • Email:

Occidental Life Insurance Company of North Carolina • Email:

Pioneer American Insurance Company • Email:

Pioneer Security Life Insurance Company • Email:

P.O. Box 2549 • Waco, TX 76702-2549 • 800-736-7311

Before completing this statement, read the attached instructions.

By furnishing forms and investigating the claim, the company does not admit that there is any insurance in force and does not waive any

of its rights or defenses.

1. Policy Numbers:__________________________________________________ Amounts:______________________________________________

2. Deceased's name in full:_________________________________________________________________ Marital Status:_____________________

3. Residence at death: Street:____________________________ City:__________________________State:_______________ Zip:_________

4. Usual Occupation (not just Retired): ____________________________________________________________________________________

5. a. Date of deceased's birth: _________________________________________ b. Place of birth:___________________________________

6. a. Date of death: ___________________________________________________ b. Place of death:____________________________________

c. Cause of death: ____________________________________________________________________________________________________

Note: Complete questions 7 through 11 only if policy has been in force less than 2 years and / or accidental benefits are claimed.

7. Date deceased first complained of, or gave other indications of his / her last illness:_____________________________________________

8. When did deceased first consult a physician for his / her last illness?_______________________________________________________________

9. On what date did deceased last attend to his / her usual work?___________________________________________________________

10. Give names and address of all physicians who attended deceased during the last five years prior thereto:

Names

Addresses

Date of Attendance

Disease or Condition

11. In what other companies, and for what amounts, was the life of the deceased insured under accident and / or life policies?

___________________________________________________________________________________________________________________

12. I hereby certify that the policy of insurance for the listed policy has been

ENCLOSED

LOST

DESTROYED

(If policy is enclosed we must have original; a photocopy is not acceptable)

13. Taxpayer I.D. Information:

Enter the claimant's taxpayer identification number

BENEFICIARY / CLAIMANT'S SS. NO.

TAX I.D. NO.

in the appropriate box. For most individuals

this is your social security number

Note: If the account is in more than one name, see the chart for guidelines on which number to give the payer. If the Social Security number or Tax I.D.

number is not provided, and backup withholding is applicable, taxes will be withheld from the proceeds.

CERTIFICATION - Under penalties of perjury I certify that

(1) The number shown on this form is my correct Taxpayer Identification Number (or I am waiting for a number to be issued to me) and

(2) I am not subject to backup withholding either because I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as

a result of a failure to report at interest or dividends or the IRS has notified me that I am no longer subject to backup withholding.

PLEASE

CLAIMANT'S SIGNATURE

DATE

SIGN

HERE

14.

Dated at______________________________________________this_______________day of_____________________________, 20______.

City & State

Claimant's Signature

15.

__________________________________________Date of Birth_______________Relationship_____________________