Missing Life Insurance/Annuity Search Request
Mike DeWine, Governor
Jon Husted, Lt Governor
Jillian Froment, Director
Consumer Service Division, 50 W Town Street, 3rd Floor - Suite 300, Columbus OH 43215
614-644-2673 | 800-686-1526 | 614-644-3744 (Fax) | insurance.ohio.gov
CONFIDENTIAL PERSONAL INFORMATION
INS2502 (Rev. 09/2019)
Page 2 of 2
Requestor’s Contact Information (Please print)
Date of Request
Print Full Name of Requestor
Mailing Street Address of Requestor
City, State, Zip of Requestor
Requestor’s E-mail Address
Requestor’s Daytime Phone Number
Deceased Person’s Information (Please print)
Full Name of Deceased Insured
(First, MI, Last)
Other legal names previously used
(i.e. maiden name)*
Date of Birth
Social Security Number
Current & Previous Address(es)*
City, State, Zip Code
* Please attach separate page if more space is needed.
Relationship of Requestor to Deceased Person (check all that apply)
Spouse Executor or Legal Representative Child (18 or Older) Attorney
Other (please specify)
Requestor’s Certification and Notarized Signature:
I certify that I have made a diligent search of the deceased person’s records and property, including bank statements, safety deposit
boxes, etc., and have made inquiries to family members to identify all in force individual life policies or individual annuity contracts
that I have reason to believe covered the life of the deceased person named above. I understand that life insurance companies will
respond to me directly ONLY IF they have reason to believe that this deceased person has any individual policies in force with them
AND that I am authorized to receive this information. I further understand that the Department’s only role in connection with this
request is to forward to all Ohio licensed life insurance companies this completed Missing Life Insurance/Annuity Search Request
form and a photocopy of the certified death certificate that I have provided. I understand that a life insurance company may require
additional information from me, including documentation of my legal authority to request or obtain information about the deceased
person that I have named. For the purposes of privacy and protection of confidential personally identifiable information, I understand
that all original documents that I submit to the Ohio Department of Insurance will not be returned to me. I further understand that all
original documents will be destroyed pursuant to Department Retention Schedules.
I certify that the information that I have provided is complete and accurate in all respects.
Requestor’s Signature:_____________________________________________________
Sworn to and subscribed in my presence this _______ day of _______________, 20____.
By____________________________________________ NOTARY
Notary Signature__________________________________________________________ SEAL
Notary Public, State of______________________________. My Commission Expires___/___/_____.
My Notary Commission is recorded in the County of _______________________________________.
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