Proofs Of Death - Claimants Statement Page 2
ADVERTISEMENT
1
2
3
4(Page 2)
PROOFS OF DEATH
NOTES TO DOCTOR:
The Medical certification follows the recommendations of the World Health Assembly made in
Geneva on July 24, 1948. It has been accepted by all States in this country and in Canada.
In the interest of accurate vital statistics, please conform to the International List of the Causes
of Death.
This section may be completed by Funeral Director or Coroner if the policy is $10,000 or less. This section may only be completed
by an Attending Physician if the policy is greater than $10,000; or, a certified copy of the death certificate may be submitted in
lieu.
Full name of deceased
Date of death
Residence at death
Place of death
Date of birth
(If hospital or Institution, give name.)
Interval between onset and death
Cause of death (Enter only one cause for each of a, b, and c.)
Disease or condition directly leading to death: (This does not mean the mode of dying,
such as heart failure, asthenia, etc. It means the disease, injury or complications which
caused death.)
(a)
(a)
Antecedents causes. (Morbid conditions, if any, giving rise to the above causes (a) stating
the underlying cause last.)
(b)
Due to (b)
(c)
Due to (c)
Other significant conditions: (Contributing to the death but not related to the disease or
condition causing death.)
Any person who, with intent to
___________________________________________________
defraud or knowing that he is
Signature of Physician, Coroner, Funeral Director
facilitating a fraud against an insurer,
STRIKE OUT
submits an application or files a
___________________________________________________
TITLES NOT
claim containing a false or deceptive
Address
APPLICABLE
statement is guilty of insurance fraud
___________________________________________________
and is subject to criminal and civil
penalties.
___________________________________________________
___________________________________________________
Name of Funeral Home
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business