Claimants_Statement_Form.pdf - DEATH CLAIM CLAIMANT\u2019S STATEMENT Please use this form to submit a claim under a policy with one or more of the

Claimants_Statement_Form.pdf - DEATH CLAIM CLAIMANTu2019S...

This preview shows page 1 - 3 out of 3 pages.

DEATH CLAIM - CLAIMANT’S STATEMENT SUBMIT ALL CLAIM RELATED DOCUMENTS TO: KEMPER LIFE INSURANCE SERVICES * Fax or email preferred 12115 LACKLAND RD ST. LOUIS, MO 63146 FAX: 314-819-4391 Documents can also be emailed to: [email protected] PLEASE TYPE OR PRINT THE FOLLOWING INFORMATION Name of Insured (Deceased)______________________________________ Social Security No. ____________________ List below any other names by which the Insured was known (include maiden name, nicknames, initials, common names, etc.) (________________________________________________) (_______________________________________________) (________________________________________________) (_______________________________________________) Date of Death: ____________________________________ Date of Birth: ______________________________________ Address of Insured: (Street Address): ____________________________________________________________________ (City)________________________________________________(State)___________________ (Zip Code) ____________ List any other states where the insured may have lived: _____________________________________________________ PROVIDE THE NUMBERS OF ALL POLICIES ON WHICH CLAIM IS BEING FILED: Policy Number Policy Number BENEFICIARY INFORMATION Name of Beneficiary: _______________________________________Relationship to insured_______________________ Address: (Mailing Address) ____________________________________________________________________________ (City) _____________________________________________________ (State) _____________ (Zip Code) ____________ Social Security # _________________________ Phone # (______)________________ Date of Birth _________________ Email address: _________________________________________________________ Name of Beneficiary: _______________________________________Relationship to insured_______________________ Address: (Mailing Address) ____________________________________________________________________________ (City) _____________________________________________________ (State) _____________ (Zip Code) ____________ Social Security # _________________________ Phone # (______)________________ Date of Birth _________________ Email address: _________________________________________________________ ASSIGNMENT OF PROCEEDS OF INSURANCE Have you or anyone else assigned all or any portion of the proceeds of any policy to a funeral home or any other party? q Yes q No If yes, provide the name and address of such firm or person __________________________________ __________________________________________________________________________________________________ C-0001 Rev. 03/19 Continued on Back Please use this form to submit a claim under a policy with one or more of the following Kemper Life companies: United Insurance Company of America, The Reliable Life Insurance Company, Union National Life Insurance Company, or Mutual Savings Life Insurance Company.
C-0001 Rev. 03/19 DEATH CLAIM - CLAIMANT’S STATEMENT (PART TWO)

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture