Form 3451 -Fla-07 - Claim Form - Life Insurance Plan

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Fidelity Life Association
Administrative Office:
17 Church Street
PO Box 506
Keene, NH 03431
Claim Form – Life Insurance Plan
IMPORTANT: “Statement of Claimant” must be completed in all cases. If there are two or more beneficiaries or other
claimants, each beneficiary must complete a “Statement of Claimant”. Each beneficiary must make a separate statement.
Statement of Claimant
POLICY NUMBER(S): ____________________________________________________________________________
1. Decedent Information – (Please print in ink or type)
______________________________________________________________________________________________
Name
First
Middle
Last
______________________________________________________________________________________________
Residence at Street
City
State
ZIP
time of death
______________________________________________________________________________________________
Date of Birth
Place of Death
______________________________________________________________________________________________
Date of Death
Cause of Death
Manner of Death
2. Beneficiary or Claimant Information
______________________________________________________________________________________________
Name
First
Middle
Last
______________________________________________________________________________________________
Residence
Street
City
State
ZIP
______________________________________________________________________________________________
Date of Birth
Day Time Telephone
Relationship to Deceased
________ -- ______ -- ________
Beneficiary/Claimant Social Security Number
Are you subject to back-up withholding? (Has the IRS contacted you directly to inform you that you are subject to
back-up withholding?)
Yes
No
In what capacity or title do you Claim this Insurance? Check one:
Beneficiary
Assignee
Trustee
Executor/Administrator
Guardian
Other
3. Statement of Lost Policy (Complete only if policy is unavailable for return)
I am unable to locate the original life insurance policy. I agree to return the policy to The Company if found.
4. Payment of Fund – Please Select One
Single Sum Payment
(If the proceeds are to be paid as one settlement, payment will be made under the Fidelity Life Immediate
Convenience Account, if eligible.)
Installment Payments
(Please refer to the certificate for options. If certificate is not available, please contact our office.)
Installment Option Elected: ________________________________________________________________________
Payment Frequency:
Monthly
Quarterly
Semi-Annually
Annually
(See Other Side)

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