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Liberty National Life Insurance Company - United …
Liberty National life Insurance CompanyInsurance Services Division Box 8066 McKinney, Texas 75070 PROOFS OF DEATH CLAIMANT S STATEMENTP lease read carefully Instructions on Page 1 before completing this person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state s Name in Full _____ List any other names by which the deceased may have been known such as maiden name, hyphenated name, nick name, alias, or derivative form of first and/or middle name Number(s) _____3. Deceased s Birth Date _____ 4. Date of Death_____ Cause of Death_____5. Residence of Deceased at Death _____ Street Address City and State6. Is any policy less than two years old? Yes No If Yes, complete pages 2 and 3. Signature: _____ Print Name: _____Address: _____ Street City, State, ZIPS ocial Security #: _____ - _____ -_____ Date of Birth: ____ / ____ / ____ Age: _____Phone: Home (_____) _____ Work: (_____) _____ Email Address: _____Relationship to Deceased:_____ Date: ____ / ____ / ____Signature of Witness: _____Print Name: _____
Liberty National Life Insurance Company Insurance Services Division • P.O. Box 8066 • McKinney, Texas 75070 PROOFS OF DEATH — CLAIMANT’S STATEMENT
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