Death Claim

To notify us of a claim, please fill out the form below and we will provide the appropriate information to complete the claim process.

To notify us by phone call toll free: 1-800-732-8939

Once your notice of claim has been received, you can expect our reply to be sent within 5 business days. Please be sure to indicate if you wish to receive your reply by mail or by e-mail.

Note: California beneficiaries will receive our reply by mail.

* Required fields

Insured’s Name:

Policy Number:

Date Of Birth:

Date Of Death:

Cause Of Death:

Place of Death (City, State, Country)

Your Name:

Your Mailing Address Line 1:

Your Mailing Address Line 2:

City:

State:

ZIP Code:

Your Daytime Phone Number:

Your Email Address:

Contact Preference:

E-Mail

Mail

Your Relationship to Insured:

Comments:

* Required Entries

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