Form Lhfm-Ull-1142 - Affidavit Of Survivorship
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1
2AFFIDAVIT OF SURVIVORSHIP
Please submit this form to:
GROUP LIFE CLAIM DEPARTMENT
PLEASE PRINT
The Union Labor Life Insurance Company
8403 Colesville Road • Silver Spring, MD 20910
Phone: (202) 682-6768 • Fax: (202) 962-2939
Toll-free: (866) 795-0680
INSTRUCTIONS
This affidavit is to be completed when there is no beneficiary designated by the insured or surviving at the death of the insured. It is to be completed by all of the
members of the first class, in descending order, in which there is at least one surviving member.
Classes of Successive Preference Beneficiaries
1. Surviving Spouse
2. Surviving Children
3. Surviving Parents
4. Surviving Brothers and Sisters
5. Executors or Administrators
Any class other than that whose members are completing the affidavit, in which there are surviving members, should be stricken from the final paragraph of the affidavit.
TO BE COMPLETED WHEN THERE IS NO BENEFICIARY DESIGNATED OR SURVIVING UPON THE DEATH OF THE INSURED
State of:
County of:
Full name:
SSN:
, being duly sworn states:
Full name:
SSN:
, being duly sworn states:
Check one:
I am the nearest sole surviving relative of the deceased listed below
We are the nearest surviving relatives of the deceased listed below
who was insured by Certificate No.
,
Name of Decedent
issued under Group Policy No.
, by The Union Labor Life Insurance Company.
At the time of death the decedent,
was survived by no spouse, no child or children, no parent
or parents, and no brothers or sisters other than the person(s) named in this affidavit.
X
Signature:
Relationship:
Date of birth:
X
Signature:
Relationship:
Date of birth:
Sworn to me on this
day of
, 20
X
Signature of Notary Public:
PLEASE COMPLETE ALL PAGES
LHFM-ULL-1142 rev 04/16
Page 1 of 2
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