C-0001 Rev. 06/20
DEATH CLAIM - CLAIMANT’S STATEMENT (PART TWO)
5. DOCTOR/HOSPITAL INFORMATION
IF ANY POLICY IS LESS THAN TWO YEARS OLD OR IF THE DEATH WAS BY ACCIDENTAL MEANS, PLEASE COMPLETE THIS SECTION.
Please list any doctors, hospitals, or medical providers that treated the insured/deceased during the past ve years. Should addional
space be required, please include on an addional sheet of paper. If none are known, please indicate so.
Name of Doctor(s) or Hospital(s):_____________________________________ Telephone No.:_______________________________
Address: ______________________________________City: __________________________ State:______ Zip Code:_____________
Name of Doctor(s) or Hospital(s):_____________________________________ Telephone No.:_______________________________
Address: ______________________________________City: __________________________ State:______ Zip Code:_____________
Name of Doctor(s) or Hospital(s):_____________________________________ Telephone No.:_______________________________
Address: ______________________________________City: __________________________ State:______ Zip Code:_____________
6. MEDICAL AUTHORIZATION
Name of Insured: _______________________________ Date of Birth: ______________ Social Security #: _____________________
Upon presentaon of this signed authorizaon or a copy thereof, I authorize any licensed physician, medical praconer, hospital,
clinic, pharmacy, denst, coroner/medical examiner, insurance or reinsuring company, the MIB, Inc. (formerly the Medical Informa-
on Bureau) consumer reporng agency, employer, or other medical or medically related facility or other person or enty possessing
medical or non-medical informaon or having any records or knowledge of the above-listed Insured or the Insured’s health to give
to the Claims Department of the appropriate Kemper Life company, or any authorized representave, any and all such informa-
on which may include but is not limited to drug, alcohol, psychiatric, HIV infecon, or AIDS related informaon. I understand this
informaon will be used to evaluate this life insurance claim and that failure to provide this authorizaon may impede the ability
of Kemper Life to evaluate this claim. I understand I have the right to revoke this authorizaon at any me by subming a wrien
revocaon except to the extent Kemper Life has taken acon in reliance on the authorizaon. I understand that the informaon dis-
closed per this authorizaon may be subject to redisclosure by the recipient and no longer protected by HIPAA. I understand that this
authorizaon is valid from the date of signing for the duraon of this claim or as required by law. I understand that I am entled to a
copy of this authorizaon upon receipt of my wrien request to Kemper Life. I agree that a copy of this authorizaon shall be valid as
the original.
Signature of Authorized Representave: _______________________________________ Date: _______________________________
Printed Name: _________________________________________ Relaon to Insured or Descripon of Authority:________________
7. CLAIM AUTHORIZATION
I/We arm and declare the above and foregoing statements to be true and correct to the best of my/our knowledge and belief. I/We
will furnish any addional proof the Company may request.
Signature of Beneciary/Claimant Date Signed
Relaonship to Deceased
Signature of Beneciary/Claimant Date Signed
Relaonship to Deceased
