PROOF OF LOSS - ACCIDENTAL DEATH
Global Claims Administration
NAME OF GROUP:
3195 Linwood Rd, Suite 201
Cincinnati, OH 45208
GROUP POLICYHOLDER/EMPLOYER INSTRUCTIONS
In order to assure prompt processing of this claim, please forward the claim form to the Beneficiary. The Employer/Administrator must complete PART A in its
entirety. Due to recent changes in tax laws, the Beneficiary will be required to complete PART B. Be certain that PART C on the reverse side is completed in
full and signed by the Beneficiary.
Return this form to the above address.
In addition to the claim form, the following items are required:
(1) A Certified Copy of the final death certificate;
(2) Your company's enrollment benefits form and Beneficiary Designation;
(3) Confirmation of employee's Principal Sum and current premium payment;
(4) The Police Report, any Autopsy Report, and any newspaper clippings.
(5) If Business Travel, a copy of employee's itinerary prior to the accident, purpose of trip, destination to and from trip, and confirmation that trip was authorized
by the company.
Every question must be fully answered. We reserve the right to require or to obtain further information should it be deemed necessary. If there is more than
one beneficiary, all may join in one statement, or a separate form will be furnished for each if desired.
PART A: GROUP POLICYHOLDER/EMPLOYER INFORMATION
GROUP POLICYHOLDER/EMPLOYER ADDRESS
DIVISION NAME AND ADDRESS
ACCIDENTAL DEATH BENEFIT IN FORCE
EMPLOYEE'S NAME AND ADDRESS
EFFECTIVE DATE OF COVERAGE
SOCIAL SECURITY NUMBER
DATE OF DEATH
TERMINATION DATE OF COVERAGE
SALARY ON DATE LAST WORKED (HRLY/WKLY/MTHLY/ANNLY)
DATE PREMIUM PAID TO
DATE LAST WORKED
STATUS ON DATE LAST WORKED:
PREMIUM WAIVER FOR DISABILITY
APPROVED LEAVE OF ABSENCE (EXPLAIN)
If Claim is For Dependent, Provide the Following:
DEPENDENT'S NAME AND ADDRESS
SOCIAL SECURITY NUMBER
AMOUNT OF BENEFIT
DEPENDENT'S DATE OF BIRTH
NAME AND ADDRESS OF EMPLOYER
GROUP POLICYHOLDER/EMPLOYER SIGNATURE
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
PLACE (CITY, STATE)
BY (THEIR AUTHORIZED REPRESENTATIVE)
PART B: IMPORTANT TAX INFORMATION
To Be Completed by Beneficiary
Social Security Number/
Tax ID Number
Please Print or Type Name of Beneficiary
Under penalties of perjury, I certify: that the Social Security/Tax ID Number shown above is my correct Social Security or Taxpayer Identification Number.
Be Certain Part C on the Reverse Side is Completed
AccDeath - 5/2016