Fillable Proof Of Death Claim Form - Life Insurance Benefits (Page 4 of 8) in pdf

Standard Insurance Company

Life Insurance Benefits

Life Benefits Department

Beneficiary Statement

PO Box 2800 Portland OR 97208 800.628.8600 Tel

Tax Information

Under the Federal Income Tax law, we are required to request that you (as the payee) provide Standard Insurance Company

(as payor) with your correct Social Security Number or Taxpayer Identification Number.

Please read and complete the following information in order to comply with Federal Income Tax law.

Certification — Under Penalties Of Perjury, I Certify That:

1. The number shown on this form is my correct Social Security/Taxpayer Identification Number (or I am waiting for a

number to be issued to me), and

2. I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) 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 all

interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding.

Certification Instructions — Check here if you are subject to backup withholding 

Method Of Payment —

1. Payment by Check

Funds under $25,000, and for policies issued in and for residents of California, Florida, Kentucky, Louisiana, Maryland and

Rhode Island, payment will be made in a lump sum, by check to the policyholder unless requested otherwise.

2. Payment by SSA

Beneficiaries may receive their funds of $25,000 and above via Standard Secure Access (SSA) in accordance with the terms of

the group policy. SSA is a convenient, interest-bearing checking account in which life insurance proceeds are deposited. With

SSA, you are able to earn interest on the life insurance proceeds while taking the time to weigh important financial decisions

that often follow the death of a loved one.

The Beneficiary will be mailed a checkbook, once the claim is approved. In addition, all SSA accountholders have access to

24-hour customer service via a voice response unit (VRU) and a dedicated customer service team.

If you decide to assign a portion of your benefits to a funeral home, please include a notarized assignment form (supplied by

the funeral home) and an itemized copy of the funeral bill. A separate check for the amount of the assignment will be delivered

directly to the funeral home.

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 6 of this form.

Signature of Beneficiary (please use dark ink and sign as you would a check)

Relationship to Deceased

Name (please print)

Date of Birth

Beneficiary’s Social Security No./Taxpayer ID No. (required)

Mailing Address (if this is a PO Box, a street address is required)

City

State

Zip Code

Street Address (only if your mailing address is a PO Box)

City

State

Zip Code

Work Phone No.

Home Phone No.

Policyholder

Name of Deceased:

Use Only

Group Policy No.:

4 of 8

SI 1794

(8/16)

Proof Of Death Claim Form - Life Insurance Benefits Page 4

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