USE THIS FORM ONLY WITH CLAIMS FOR NATURAL DEATH BENEFITS OF $15,000 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the name of the insured individual in the designated field. Ensure accuracy as this is crucial for processing the claim.
3. Next, input the Social Security Number of the insured. This information helps verify identity and eligibility for benefits.
4. Fill in the policy number associated with the insured. This links your claim to the correct insurance policy.
5. Indicate the date of death clearly, ensuring it matches any official documentation you may have.
6. Provide the date of birth of the deceased in the specified field to confirm their identity further.
7. In the section for place of death, write down where the individual passed away, which may be required for verification purposes.
8. Detail the principal cause of death in a clear manner. This information is essential for claims processing.
9. Finally, ensure that a licensed physician, coroner, or funeral director completes and signs the form, including their printed name and contact details.

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