Group Insurance Death Claim Form

If the cause of death is an injury or accident include a copy of any related police report and or newspaper articles.

Group insurance death claim form. Submit a life accidental death dismemberment or waiver claim. Forms required for death claim disability and hospitalization benefits. Section 1 must be completed if the claim is for an employee member or for a dependent of an employee. Be sure to read the instructions on the form.

To begin the claims process a family member or friend of the deceased should complete and submit this form. Group life insurance or accidental death and dismemberment insurance rider claims please provide a certified copy of the deceased person s birth certificate and death certificate. Only one proof of death is required for the deceased even when there are multiple claimants and or policies. The required form of proof will be indicated in the claims packet sent to the beneficiary.

You will have to print out the claim form and give or mail it to the employing agency with a certified copy of the death certificate. Giry state zip 1 27. Legal residence at time of death city and state 6. Use for employee member and dependent death claims how to complete and submit a group life insurance claim form.

Anthem life insurance company claims center statement of death group claim form. The document required varies depending on the dollar amount of the benefit payment or circumstances of death see table below. Insured s full name last first middle 2. If you wish you may complete the claim form ahead of time by downloading the form from this website.

Death and disability hospitalization claim. Coma brain injury claim form enrollment and beneficiary form group life insurance conversion information notification of death proof of death proof of loss total and permanent disability benefits application statement of claim for hospital confinement benefits uniform transfers to minor act. Accidental death amount 19. Social security number or fegli claim number.

Telephone number 0 no remarks. Group life insurance claim form. Claim for death benefits federal employees group life insurance program part a. This service is offered by cigna group insurance to employers who wish to file a life accidental death dismemberment or waiver claim for their employees and or their employees dependents.

Date of death mm dd yyyy 4. Employers complete address street or box i 26. Complete sections 1 2 3 4 and 5 of the group contract holder statement portion of the group life insurance claim form. Basic life or dependent life amount 18.

Date of birth mm dd yyyy 3. Fax number 1 title of employer s representative 23.