Proofs Of Death - Claimants Statement Page 4

(Page 4)

COMPLETE THIS SECTION ONLY WHEN THE POLICY IS LESS THAN TWO (2) YEARS OLD

1. Names and addresses of all physicians who attended or prescribed for deceased within the last six years preceding death:

NAMES

ADDRESSES

DATES OF ATTENDANCE

DISEASE OR CONDITION

2. Name and address of health carrier, including Medicare, HMO, PMD, Group, Individual, Disability, etc.

NAMES OF COMPANIES

ADDRESSES

3. If deceased had life insurance with other companies, list names of companies and addresses below:

NAMES OF COMPANIES

ADDRESSES

4. Was deceased at any time treated or confined at a hospital, asylum, rehabilitation center or nursing home? _____________

If “Yes, ” when? _____________________________________ Where? _________________________________________

5. On what date did deceased last attend to his/her usual work? Date _____________________________________________

F9042

0 votes

Parent category: Business