Benefits
Eff
PTD
For H.O. Use Only
Proof of Death
CL-PD (8-09) Page 1 of 2
Attention: Claims Department
P.O. Box 1650
Little Rock, Arkansas 72203-1650
Telephone (800) 370-5856 E-mail: claims@usablelife.com
Date
I certify that the information furnished in support of this claim is true and correct.
AUTHORIZATION TO OBTAIN INFORMATION
USAble Life's Group Number
Date of Birth
Name of Employee
Certificate/ID Number
Address City, State, Zip
Date Employed
Date on which employee was last "actively at work"
Reason Employee stopped work Termination of EmploymentRetirementDisabilityDeath
Date on which employment terminated
Date of Death
Signature Title Date
Address City, State, Zip
EMPLOYER'S STATEMENT
BENEFICIARY'S STATEMENT
Relationship
To Deceased
Signature of
Nearest Relative
Date
DEATH OF AN INSURED EMPLOYEE
Important: Read Carefully
FRAUD WARNING: Except as noted in separate Fraud Notice, it is or may be a crime to knowingly provide false,
incomplete or misleading information to an insurance company for the purposes of defrauding the company or
other person. Penalties may include imprisonment, fines, and denial of insurance benefits in accordance with
applicable state law.
This form is to be completed upon the death of an insured and forwarded to USAble Life. In addition, an official
Certified Death Certificate is required. If death was due to suicide, homicide or accidental means, a copy of the
investigating officer's report is also required. By furnishing this form and investigating the claim, USAble Life
shall not be held to admit the validity of any claim or to waive the breach of any condition of the policy.
(See Page 2/reverse side for death of an insured dependent.)
Address
Relationship To Deceased
Beneficiary Signature
Beneficiary's Date of Birth Beneficiary's Social Security #
Daytime
Telephone
City, State, Zip
Beneficiary's Name (Please print)
I hereby authorize any licensed physician, medical practitioner, hospital, clinic, or other medical or medically related facility, insurance
company, health maintenance organization, the Medical Information Bureau (MIB), government entity (federal, state, or local), reinsurer,
or other organization, institution or person that has information, records or knowledge of the deceased or his health, past or present, to
furnish such information to USAble Life (the “Company”), or its agents. I understand that the Company may disclose the information
to MIB, other insurance carriers, reinsurers, claim management/investigation firms, agents, employees and others who have a legitimate
business interest in obtaining the information in connection with underwriting or claim processing. A photostatic copy of this Authorization
shall be as valid as the original.
Claim is for (check all applicable)
2. Do you recommend payment of this claim? Yes No
1. Did the deceased die in a motor vehicle accident? Yes No
If yes, was the deceased wearing a seat belt? Yes No
Basic Group Term Life Amount $ ______________________
Supplemental/Vol. Group Term Life Amount $ _____________
Accidental Death Amount $ __________________________
Optional SeatBelt Rider (if applicable) Amount $ __________
Employer Telephone
Name (Please print or type) Fax Number
FRAUD WARNING: Except as noted in separate Fraud Notice, it is or may be a crime to knowingly provide false, incomplete or
misleading information to an insurance company for the purposes of defrauding the company or other person. Penalties may
include imprisonment, fines, and denial of insurance benefits in accordance with applicable state law.
Please use blue or black ink to complete.
