Report Of Death Of Family Member - Prudential
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1
2Office of Servicemembers'
Group Life Insurance
REPORT OF DEATH OF FAMILY MEMBER
This form is being completed to report a (check one):
Branch of Service address
Death of Spouse (Complete Parts I, II & IV)
Death of Child (Complete Parts I, III & IV)
PART I – Service Member Information (Service member must be insured under SGLI for Family Coverage to be in effect.)
1. Name (first middle last)
2. Social Security Number
3. Duty status
4. Gender
Active Duty
Female
Ready Reservist
Male
5. Certifying Command location and address
6. Home mailing address
7. Telephone number
PART II – Information of Deceased Spouse
8. Name (first middle last)
9. Social Security Number
10. Gender
Female
Male
11. Date of birth (mm/dd/yyyy)
12. Date of death (mm/dd/yyyy)
13. Please check all that apply
Civilian death certificate attached
Form SGLV 8286A attached (if required)
14. Date of marriage to service member (Only if
15. The spouse of the service member with SGLI coverage is eligible for spouse coverage as provided
deceased was a member of the uniformed
by Public Law 107-14 and Public Law 112-239.
services and marriage occurred on or after
.
a. Dependent spouse was covered for $
1/2/2013) (mm/dd/yyyy)
Yes
No
b. Were premiums for spouse’s coverage collected from the member’s pay?
c. Amount owed: $
for the months
through
.
PART III – Information of Deceased Child
16. Name (first middle last)
17. Social Security Number
18. Date of death (mm/dd/yyyy)
19. Gender
20. Date of birth (mm/dd/yyyy)
21. Is the civilian death certificate attached?
Female
Male
Yes
No
22. The dependent child of the service member with SGLI coverage is automatically insured for $10,000 by law.
a. Service member is the child’s:
biological or adoptive parent
step-parent
b. Is the child’s other parent in the military?
No
Yes
If yes, please provide:
• Other parent’s name
• Last four digits of his/her Social Security Number
• Branch of Service
c. Does the child have any step-parents in the military?
Yes
No
If yes, please provide:
• Step-parent’s name
• Last four digits of his/her Social Security Number
• Branch of Service
d. Were the child’s parents married at the time of child’s death?
Yes
No
PART IV – Reporting Information
23. Certifying Command signature
24. Command agency point of contact (please print)
Date:
25. Telephone number
GL.2011.090
Ed. 05/2013
SGLV 8700
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