Life-Death Benefit Claim Form V08.19.docx 2026

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The document provides detailed instructions for submitting a death benefit claim to Trustmark Insurance. It outlines the necessary supporting documentation, including certified death certificates and medical records, as well as required sections of the claim form that must be completed accurately to avoid delays. Additionally, it includes information on electronic communication consent, fraud warnings specific to various states, and authorization for the release of medical information. The document emphasizes the importance of thoroughness in the claims process.

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Click ‘Get Form’ to open the Life-Death Benefit Claim Form V08.19.docx in the editor.
Begin by filling out the 'Statement of Beneficiary' section. Enter the deceased's full name, date of birth, and residence address. Ensure that all fields are completed accurately to avoid delays.
Provide details regarding the cause of death, including whether the deceased was confined to a hospital at the time of death. Include names and addresses of physicians who treated the deceased in the past five years.
Complete the 'Disclosure Authorization' section by providing your signature and necessary personal information. This allows Trustmark to access relevant medical records.
If applicable, fill out the 'Attending Physician Statement' with details from the physician regarding treatment history and causes of death.
Review all sections for completeness and clarity before submitting your claim through our platform.

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