Proofs Of Death - Claimants Statement
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4Globe Life And Accident Insurance Company
Insurance Services Division • P.O. Box 8076 • McKinney, Texas 75070
PROOFS OF DEATH — CLAIMANT’S STATEMENT
Please read carefully Instructions on Page 3 before completing this statement.
Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject
to fines and confinement in state prison.
1. Deceased’s Name in Full _____________________________________________________________________________
List any other names by which the deceased may have been known such as maiden name, hyphenated name, nick name, alias, or
derivative form of first and/or middle name _________________________________________________________
2. Globe Life And Accident Policy Number(s) _______________________________________________________________________
3. Deceased’s Birth Date _________________________________________
4. Residence of Deceased at Death _______________________________________________________________________
Street Address
City and State
5. Date of Death ____________________ Cause of Death ____________________________________________________
6. Do you desire payment in a lump sum or under a Policy Settlement Option? _____________________________________
7. Is any policy less than two years old? ❒ Yes ❒ No
If “Yes, ” complete page 4.
AUTHORIZATION
I authorize any physician, medical practitioner, hospital, clinic or medically related facility, employer, or insurance company having
medical information concerning the Deceased, to permit Globe Life And Accident Insurance Company or its authorized representatives
to review, copy, or otherwise obtain details of all such medical information, including but not limited to, drug abuse, alcoholism or
psychiatric treatment. I agree that a photocopy or facsimile of this authorization shall be as effective and valid as the original.
Signature: ___________________________________________________
Print Name: _____________________________________________
Address: _________________________________________________________________________________________________________
Street
City, State, ZIP
Social Security #: _________ - _______ - _________________
Date of Birth: ____ / ____ / ____ Age: _________
Phone: Home (_______) ____________________________
Work: (________) __________________________
Relationship to Deceased: ____________________________
Date: ____ / ____ / ____
Signature of Witness: _______________________________________________ Print Name: _________________________________________________
Signature: ____________________________________________
Print Name: _____________________________________________
Address: _________________________________________________________________________________________________________
Street
City, State, ZIP
Social Security #: _________ - _______ - _________________
Date of Birth: ____ / ____ / ____ Age: _________
Phone: Home (_______) ____________________________
Work: (________) __________________________
Relationship to Deceased: ____________________________
Date: ____ / ____ / ____
Signature of Witness: _______________________________________________ Print Name: _________________________________________________
GLB1916 0211
F9042
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