Proofs Of Death - Claimants Statement (Page 3 of 4) in pdf

(Page 3)

AGREEMENT TO BE EXECUTED IN EVENT POLICY PROCEEDS ARE ASSIGNED

Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a

claim containing a false or deceptive statement is guilty of insurance fraud and is subject to criminal and civil penalties.

IT IS HEREBY AGREED by the subscribers hereto that Policies Nos. _____________________________________________

issued or reinsured by Globe Life And Accident Insurance Company on the life of _______________________________________

have been duly assigned to ___________________________________ as collateral security; that there is now due to said

________________________________________________________________________ , Assignee, on account of said debt,

the sum of __________________________________________________ Dollars ($

);

and that all claims under Policies may be settled by the payment of :

(A) _____________________________________________________________ Dollars ($

) to said

________________________________________________________________, Assignee, and (B) of the balance due on

and under Policies to __________________________________________________________________, Claimant

IN TESTIMONY WHEREOF we have hereunto set our hands this _________ of ____________________, _________.

day

month

year

_______________________________________________

______________________________________, Assignee

Assignee’s Tax ID #

______________________________________ Address

Street

(_________)_____________________________________

_______________________________________________

Telephone Number

City

State

ZIP

Witness ________________________________________

______________________________________, Claimant

NOTICE TO FUNERAL DIRECTOR:

If assigned amount exceeds $10,000, a copy of the itemized bill must be attached.

INSTRUCTIONS

1. Claimant’s Statement (Page 1) must be executed by the beneficiary or beneficiaries named in the policy. The Social Security

Number is required for each claimant.

2. If part or all of the policy proceeds are assigned, the agreement at the top of Page 3 is to be executed by the beneficiary

and assignee.

3. When the beneficiary is a minor, or is otherwise incapacitated, the Claimant’s Statement (Page 1) must be executed by the

guardian, with letters of guardianship attached.

4. If any named beneficiary in the policy has died before the insured, a death certificate of such deceased beneficiary must

be attached.

5. Where the claimant is the executor or administrator of the estate of the insured, such person will complete Claimant’s Statement

(Page 1), and letters testamentary or letters of administration must be attached.

6. If the claimant is a partnership, Claimant’s Statement (Page 1) should be completed in the name of the partnership by a general

partner; and if claimant is a corporation, in the name of the corporation by an officer of the corporation with the corporate seal

affixed.

7. If the death of the insured was due to accident, suicide or homicide and any policy listed on Page I is less than two years old or

provides for accidental death benefits, a certified copy of the coroner’s verdict or report of coroner’s medical examiner, dated

newspaper reports and all available information must accompany this proof of death.

8. If policy is less than two years old, Page 4 must be completed.

Proofs Of Death - Claimants Statement Page 3

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