Fillable Proof Of Death Claim Form - Life Insurance Benefits (Page 2 of 8) in pdf

Proof Of Death Claim Form - Life Insurance Benefits Page 2

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Standard Insurance Company

Life Insurance Benefits

Life Benefits Department

Proof of Death Claim Form

PO Box 2800 Portland OR 97208 800.628.8600 Tel

Please type or print. Forms may be returned for unanswered questions.

Name of Deceased:

Effective Date of Member’s Insurance:

Social Security No.:

Date of Membership/Employment:

Date of Birth:

Date member was last actively at work: Had employment terminated prior to death?



Yes

Date:

Date of Death:

Reason member ceased working:



Death

Illness

Other

(explain)

If Dependent Claim, Name of Member:



Premiums paid through month of death?

Yes

Group Policy No.:

Insurance Class (see contract)

Monthly or annual salary:

Occupation:

Date of last salary increase:

Amount of insurance claimed:

Salary prior to increase:

Basic Life

Dependents Life $

Usual number of hours employee worked per week:

Additional Life

Other

(specify)

Amount of monthly premium paid for the insured:

Accidental Death $

Member also had the following claims with Standard Insurance Company:

Member was:

(check all that apply)



Long Term Disability

Full-time

Union

Hourly



Short Term Disability

Part-time

Non-Union

Salaried



Waiver of Premium

Commissioned

Active

Retired

Name of Beneficiary

Social Security No.

Relation

Date of Birth

Address*

Phone

*If the mailing address is a PO Box, we must have a street address in addition to the PO Box mailing address.

Remarks:

In addition to this form, the following items are required: (Note: original documents will not be returned)

�

Beneficiary Statement.

Photocopy death certificate.

�

Photocopies of enrollment forms and any subsequent beneficiary changes.

For AD&D and Seat Belt Claims, photocopies of newspaper clippings,

police and accident reports, or other information regarding

the accident.

Acknowledgement

I hereby certify that the answers I have made to the foregoing questions are both complete and true to the best of my knowledge and belief. I acknowledge

that I have read the fraud notice on page 3 of this form.

Signature of Benefit Administrator

Date

Name of Employer or Association

Benefit Administrator’s Name

Street Address

(Please print)

(

)

Phone No.

City

State