Aglc180a 2025

1. Click ‘Get Form’ to open the aglc180a in the editor.
2. Begin with the Claimant’s Statement on page 1. Fill in all required information about the deceased, including their full name, date of birth, and cause of death.
3. Indicate your relationship to the deceased and provide your contact details. If there are multiple policies, list all policy numbers.
4. Complete the Payment of Policy Proceeds section on page 2 by selecting your preferred payment option. Ensure you sign and date this section.
5. On page 3, fill out the Withholding Elections for Tax section. Enter your Social Security Number or Taxpayer Identification Number as required.
6. If applicable, complete page 4 regarding Accidental Deaths or Homicides by providing necessary details about the incident.
7. Finally, ensure you complete and sign the HIPAA Authorization form included in the document before submitting your claim.

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