Proof Of Death For Group Insurance Form
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1
2UnitedHealthcare Speciality Benefits
PO Box 7149
United HealthCare Insurance Company
Portland, ME 04112-7149
United HealthCare Insurance Company of Ohio
United HealthCare Insurance Company of Illinois
1-888-451-7986
Fax: 1-800-980-0298
PROOF OF DEATH FOR GROUP INSURANCE
INSTRUCTIONS:
Any person who knowingly and with intent to injure, defraud or
1. Claimant please fill in and sign section below.
deceive any insurance company files a notice of claim containing
2. Certified Death Certificate must be included in proofs.
any false, incomplete or misleading information may be guilty of
3. Attach copy of police report, if accidental.
a criminal act punishable under law.
4. Attach copy of toxicology report if driver.
SECTION 1
CLAIMANT’S SIGNATURE
Deceased's Name
Name of Insured Employee:
Deceased's S.S. Number
Deceased's Address
Name of Employer
Group Policy Number
Deceased date of BIRTH
Deceased’s date of DEATH
Place of death
(if in hospital, give name and address of hospital)
Cause of death
Your date of birth
Your Name
Telephone Number
Your Relationship to Deceased
Your Address
SIGNATURE AND SOCIAL SECURITY VERIFICATION
Please review the following statement and sign your name the way you would ordinarily sign a check. We are requesting your signature for
two purposes: first, to certify your Social Security number; and second, to confirm your signature for the bank that will clear your checks.
Under the penalties of perjury, I certify that (1) the number I have documented on this form is my correct taxpayer identification number,
and (2) I am not subject to backup withholding either because I have not been notified by the Internal Revenue Service (IRS) that I am
subject to backup withholding as a result of failure to report all interest or dividends, or because the IRS has notified me that I am no longer
subject to backup withholding.
_______________________________________________
_________________________________________________________________
Social Security Number or Taxpayer Identification Number
Signature
Date
(IMPORTANT: Sign your name the way you would ordinarily sign a check)
The above statements are true and complete to the best of my knowledge and belief. I understand and agree that by furnishing the form and
investigating the claim, the United HealthCare Insurance Company shall not be held to admit validity of any claim, or waive any of its rights,
or any of the conditions of the policy. I hereby authorize United HealthCare Insurance Company to obtain any medical or hospital records
on the deceased. A photostat of this authorization will be as valid as the original authorization.
(OVER)
042-1021 1/08
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