Accidental Death Insurance Claim Form

Accidental Death Insurance Claim Form
Use this form to submit an accidental death insurance claim and provide the details and documents needed to review the claim.
Claimant and Contact Information
Claimant Full Name
First NameMiddle NameLast Name
Relationship to Deceased
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Deceased Person and Policy Details
Deceased Person's Full Name
First NameMiddle NameLast Name
Date of Birth
MonthDayYear
Date
Date of Death
MonthDayYear
Date
Policyholder Name (if different)
First NameMiddle NameLast Name
Policy Number or Last 4 Digits
Policy Type
Beneficiary Details (if applicable)
Death Circumstances and Claim Details
Date of Death
MonthDayYear
Date
Time of Death
Hour Minutes
AM/PM Option
Place of Death
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Was the death accidental?
Describe the accident and surrounding circumstances
Involved agencies and additional claim notes
Supporting Documents
Please upload legible, relevant documents that support this claim. Include the death certificate, any available police or incident report, beneficiary or claimant identification in a safe non-sensitive form, proof of relationship if needed, and any additional supporting documents.
Death Certificate
Cancelof
Police or Incident Report (if available)
Cancelof
Identification Document for Beneficiary or Claimant (safe non-sensitive form)
Cancelof
Proof of Relationship and Other Supporting Documents
Cancelof
Claim Certification and Submission Details
Date of Submission
MonthDayYear
Date
Preferred Payout/Contact Method
Signature
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Accidental Death Insurance Claim Form

Claimant and Contact Information

Deceased Person and Policy Details

Death Circumstances and Claim Details

Supporting Documents

Claim Certification and Submission Details