LIFE INSURANCE CLAIM
Policyholder Information
Please provide the following details about the policyholder:
Full Name: John Alexander Smith
Policy Number: LIF123456789
Date of Birth: January 15, 1950
Address: 123 Maple Street, Springfield, IL, 62701
Phone Number: (555) 123-4567
Claimant Information
Please provide the following details about the claimant:
Full Name: Emily Jane Smith
Relationship to Policyholder: Daughter
Address: 456 Oak Avenue, Springfield, IL, 62702
Phone Number: (555) 234-5678
Details of Death
Please provide the following information regarding the policyholder's death:
Date of Death: June 10, 2054
Place of Death: Springfield Memorial Hospital, Springfield, IL
Cause of Death: Complications from heart disease
Required Documentation
Please ensure you submit the following documents along with this claim form:
Document | Status | Details |
|---|
Certified Copy of Death Certificate | Attached | |
Original Life Insurance Policy Document | Attached | |
Proof of Claimant's Identity | copy of the passport is attached | |
Medical Records and Reports | Attached | Includes hospital discharge summary |
Any Additional Documentation Requested | None at this time | |
Payment Information
Please provide the preferred method and details for receiving the payment:
Bank Name: Springfield National Bank
Account Number: 987654321
Routing Number: 123456789
Bank Address: 789 Elm Street, Springfield, IL, 62703
Payable to: Emily Jane Smith
Declaration and Signature
Please read and sign the following declaration:
I hereby declare that the information provided in this claim form is true and accurate to the best of my knowledge. I understand that any false statements or misrepresentation may result in denial of the claim and possible legal action.
Claimant's Name: [Your Name]
Date: [Date Signed]
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