Fraternal Benefit Society Life Insurance Claim Form

Fraternal Benefit Society Life Insurance Claim Form
Submit a claim for a life insurance benefit with the required claimant, policy, and event details, plus supporting documents.
Claimant Information
Full Name
First NameMiddle NameLast Name
Relationship to Insured
Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Policy and Insured Details
Policy Number
Insured Person's Full Name
First NameMiddle NameLast Name
Membership or Certificate Reference (if applicable)
Insured Person's Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Claim Event Details
Date of Death or Claim Event
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Place of Death or Event
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Cause or Category of Claim
Other
Brief Description of Circumstances
Beneficiary and Payout Preferences
Beneficiary Name(s)
Preferred Payout Method
Special Instructions for Payment Delivery
Supporting Documents and Submission Details
Supporting Documents
Cancelof
Preferred Contact Method for Follow-Up
Additional Comments or Notes
Should be Empty: