Cs-Gl-Form-A-Dtp-Ers - Life Insurance Claim Form Page 5
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9Life Insurance Claim Form
Group Life Claims
P.O. Box 6100
Claimant’s Statement
Scranton, PA 18505-6100
1-800-638-6420
Insured's Employer Name
ISI Insurance Trust
Insured Employee - First Name
Middle Name
Last Name
In order to process your claim as quickly as possible we need some information about you and about the deceased. Each beneficiary must
submit his or her own Claimant’s Statement. Return this completed Claimant’s Statement to the Employer or directly to MetLife, in accordance
with the instructions you received with this form. Be sure to include a certified copy of the death certificate that indicates the cause and
manner of death. A certified copy of the death certificate is one that has been certified by the local Bureau of Vital Statistics or other
responsible agency, and bears a raised or colored seal. You can usually obtain one from the funeral director who handled the arrangements.
Only one death certificate need be submitted. Please note that original documents cannot be returned.
Additional Information if Beneficiary is a Minor:
If no legal guardian is appointed to handle the minor’s estate, a responsible adult should complete and sign the Claimant’s Statement on
behalf of the minor beneficiary. Be sure to complete Section A with information regarding the minor, not the party completing the form. If a
legal guardian of the minor child’s estate has been or will be appointed, the guardian must complete and sign the Claimant’s Statement. Be
sure to include a copy of court-issued guardianship papers in the claim submission to MetLife.
A. Information about the beneficiary
Middle Initial
Last
1. Your Name - First (please print in capital letters or type)
3. Date of Birth
2. Social Security No./TIN
Maiden Name (if applicable)
Male
Female
5. Day Phone Number
Evening Phone Number
6. Fax Number (optional)
4. Country of Citizenship
7. Mailing Address - Number, Street, Apt./Box No. (if any)
City
State
Zip
8. Relationship to the deceased - You are the
Spouse
Parent
Other - Explain
Child
9. If you have signed a document with a funeral home (a funeral home assignment) that
authorizes MetLife to make a payment directly to it, please attach the document and check here
B. Information about the deceased
Middle Initial
Last
1. His/Her Name - First
Maiden Name (if applicable)
2. Residence Address - Number, Street, Apt./Box No. (if any)
City
State
Zip
4. Date of Birth
5. Social Security No.
3. Marital Status
Single
Married
Divorced
Widow/Widower
Separated
6. Certified copy of death certificate is
attached (or was previously submitted)
not attached. If not attached, please explain
7. If the decedent also held an individual life insurance
policy with MetLife, please provide the policy number:
or call 1-800-638-5000 for information.
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CS-GL-FORM-A-DTP-ERS
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