Proof Of Death For Group Insurance Form (Page 2 of 2) in pdf

Proof Of Death For Group Insurance Form Page 2

SECTION 2

STATEMENT OF EMPLOYER

We certify that, to the best of our knowledge and belief, the following statements and answers are true:

Full Name of Employee

Address of Employee

Street Address

City

State

Zip

Employer and Group Policy Number

Employee’s Social Security Number

Date to which Employee’s Individual Premiums are paid

Date of Employment

Date Deceased last present at work (Performing normal duties on full-time basis)

If Employee not actively at work on date of death, give reason:

Discharged

On Leave of Absence

Quit

On Vacation

On Disability

Temporary Work Stoppage

Other, explain

Occupation or Class of Insured and scheduled hours worked

Basic Amount of Life Insurance

Supplemental Life Insurance

Name of Beneficiary*

Relationship

*Please attach any enrollment forms and beneficiary

AUTHORIZED OFFICIAL MUST SIGN BELOW:

designations you retained.

Name of Employer

Address of Employer

Telephone Number of Employer (with area code)

Signature of Employer

Proof Of Death For Group Insurance Form Page 2