Introduction

I, [YOUR NAME], solemnly declare and affirm under penalty of perjury under the laws of the State of Delaware that I am the [RELATIONSHIP TO THE DECEASED] of the late [DECEASED PERSON'S NAME], who passed away on [DEATH DATE].

Statement of Facts

I certify the following facts pertaining to the death of [DECEASED PERSON'S NAME]:

1. [DECEASED PERSON'S NAME] was a policyholder with your esteemed company and held a life insurance policy with your organization.

2. The death of [DECEASED PERSON'S NAME] occurred on [DEATH DATE], at [PLACE OF DEATH], as evidenced by the attached death certificate issued by the Delaware Department of Health.

3. I am hereby formally notifying [INSURANCE COMPANY NAME] of the death of [DECEASED PERSON'S NAME] for the purpose of claiming any life insurance benefits payable under the aforementioned policy.

4. I understand that any benefits payable under the policy will be subject to the terms, conditions, and exclusions outlined in the policy contract.

5. Enclosed with this affidavit is a certified copy of the death certificate issued by the [ISSUING AUTHORITY NAME] for your records and verification purposes.

6. I request that [INSURANCE COMPANY NAME] promptly initiate the necessary procedures to process the life insurance claim and provide guidance on any additional documentation or steps required to facilitate the claim process.

7. Please direct any correspondence or communication regarding this matter to the undersigned at the address provided above.

Signature

I hereby affix my signature to this affidavit on this [DATE].

[YOUR NAME]

[RELATIONSHIP TO THE DECEASED]

Subscribed and sworn to before me this [DATE] by [YOUR NAME], who is personally known to me or who has produced [IDENTIFICATION DOCUMENT] as identification.

[NOTARY PUBLIC'S NAME]

My Commission Expires:                               

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