Life Insurance Claimant’s Statement

Policy Number(s) _____ LCL01 03/14 Page 1 of 6 life Insurance claimant s Statement Policy number(s) Name of Deceased Other names by which the deceased may have been known (Such as maiden name, hyphenated name, nickname, derivative form of first and/or middle name or an alias) Date of Birth Date of death Social Security Number_____ Cause of Death _____ Marital Status: Single Married Widow/Widower Separated Divorced Name of Spouse Beneficiary Name Address City, State, ZIP Social Security Number _____ Date of Birth Male Female / Your Relationship to Decedent Phone Number: Day ( ) Alternate ( ) Marital Status: Single Married Widow/Widower Separated Divorced Trust/Estate Tax ID Date of Trust _____ (If Applicable) Are you a citizen of the United States of America?

Policy Number(s) _____ LCL01 03/14 Page 1 of 6 Life Insurance Claimant’s Statement Policy number(s)

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  Life, Testament, Insurance, Claimant, Life insurance claimant s statement

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