For H.O. Use Only
Proof
of Death
Attention. Claims Department
P.O. Box 1650
Little Rock, Arkansas 72203-1650
Telephone (501) 375-7200
Important: Read Carefully
WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information
in a claim for insurance may be guilty of a crime and subject to fines and
confinement in prison.
This form is
copy of the
copy of the
USAble Life
to be completed upon the death of an insured and forwarded to USAble Life. In addition, a certified
official death certificate is required.
If death was due to suicide, homicide or accidental means, a
investigating officer's report is also required.
By furnishing this form and investigating
the claim,
shall not be held to admit the validity of any claim or to waive the breach of any condition of the
policy.
Group
Certificate/ID
Number
Number
Amount
$
Name of Employee
Date
Address
City .State,
Date Employed
Date on which employee
of Birth
Zip
D
last worked full-time
Termination
of
Employment
Cause of Death
Date of Death
Do you recommend
of Insurance
payment of this claim
D Yes
DNo
Employer
Date
Signature
Title
Name (Please Print or Type)
Telephone
J
City, State, Zip
Address
I hereby authorize any insurance company. prepayment organization, employer, hospital or physician to release all information
with respect to the deceased which may have a bearing on the benefits payable under this or any other plan providing
benefits or services.
certify that the information
Date
Beneficiary's
Address
Relationship
To Deceased
Signature of
Nearest Relative
Date
Beneficiary
furnished
in support of this claim is true and correct
Signature
Date of Birth
City, State, Zip
(See reverse side for death of an insur~
CL-PD (2-98)
dependent.)
Proof
of Death
Attention. Claims Department
P.O. Box 1650
Little Rock, Arkansas 72203-1650
Telephone (501) 375-7200
Important:
Read Carefully
WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in a claim for insurance may be guilty of a crime and subject to fines and
confinement in prison.
This form is
copy of the
copy of the
USAble Life
to be completed upon the death of an insured and forwarded to USAble Life. In addition, a certified
official death certificate is required.
If death was due to suicide, homicide or accidental means, a
investigating officer's report is also required.
By furnishing this form and investigating
the claim,
shall not be held to admit the validity of any claim or to waive the breach of any condition of the
policy.
Group
Certificate/ID
Number
Number
Name of Employee
Name of Deceased
Date of Death
Cause of Death
Do you recommend
payment of this claim
D Yes
Dependent
DNo
Date
Employer
Signature
Title
Name (Please print or type)
Telephone
City, State, Zip
Address
Deceased's
)
Relationship
to Employee
Deceased's
If relationship
is shown to be "child," was deceased
If relationship
is shown to be "spouse,"
Was the deceased
a deperTdent
married at the time of death?
was deceased
and used
Date of Birth
divorced or legally separated
by you as such
for income
tax purposes?
D Yes
from you?
O Yes
O
No
D Yes
D
D
No
No
I hereby authorize any insurance company, prepayment organization, employer, hospital or physician to release all information
with respect to the deceased which may have a bearing on the benefits payable under this or any other plan providing
benefits or services.
I certify that the information
furnished
in support of this claim is true and correct.
(See reverse side for death of an insured employee.)
CL-PD (2-98)