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Filing an Assurity
Death Benet Claim
This document lists the forms and evidence generally required for submission of a claim for
death benets. This list is not exhaustive and Assurity may require additional documentation
including, but not limited to, a condential information authorization form, copies of trust and/
or estate documents, and medical records.
In order to expedite the claim process, Assurity requests that the beneciary(ies) contact
the Assurity Claims Department at 800-869-0355 Ext. 4484 for conrmation of beneciary
designations and to be advised of forms and supporting documentation required for review of
the claim.
Assurity administers many dierent plans of insurance. Please consult the contract for specic
benets, denitions, provisions, limitations and exclusions. The insured’s contract may include
optional riders providing additional insurance benets. Please contact the Assurity Claims
Department at 800-869-0355 Ext. 4484 to inquire about other potential benets.
Death Claim Requirements
Requests for Proceeds form
The Request for Proceeds form is a document that must be completed for each
designated beneficiary.
If the named beneficiary is a trust or an estate, the form must be completed by
the appropriate trustee or personal representative of the estate.
Certied death certicate
For each death claim, Assurity requires one certied death certicate with a raised
seal and listed cause of death.
Original copy of the insurance policy
Assurity asks that the original insurance policy/certicate be returned to our
home oce.
If your contract includes benets not described in this document or you have
questions, please contact Assurity’s Claims Department.
15-377-01153-18
800-869-0355 Ext. 4484
claimsinfo@assurity.com
Assurity is a marketing name for the mutual holding company Assurity Group, Inc. and its subsidiaries. Those subsidiaries include but are not limited to: Assurity Life Insurance Company and Assurity
Life Insurance Company of New York. Insurance products and services are oered by Assurity Life Insurance Company in all states except New York. In New York, insurance products and services are
oered by Assurity Life Insurance Company of New York, Albany, New York. Product availability, features and rates may vary by state.
Notication of Death
Notication of death may be reported to Assurity by calling Assurity claims at 800-869-0355 Ext. 4484, or by completing
the Notification of Death form.
Upon confirmation of beneficiary designations, the beneficiary will be adivsed of forms and supporting documentation
required for review of the claim.
NOTIFICATION OF DEATH
P
olic
y
owner’s Name Social Security No.
First Middle Last
D
eceased’s Name
First Middle Last
D
ate of birth
/ /
Date of death
/ /
(MM/DD/YYYY) (MM/DD/YYYY)
POLICY NUMBER(s)
D
o
y
ou have all of the original policies listed above? Yes No
C
ONTACT PERSON
Name
Telephone No.
( )
First Middle Last
Address
Street address City State ZIP+4
Relationship to the Insured
/ /
Signature of Contact Person Date (MM/DD/YYYY)
Direct any questions to our claims department at the phone numbers and address shown above.
0
1-030-05055 [R.02.21.12] 0103005055
Assurity
®
Life Insurance Company
Post Office Box 82533, Lincoln, NE 68501-2533
402- 476-6500 | 800-276-7619 | FAX 800-869-0368
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Completed 7 March 2021

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