Life Claims Service Center P.O. Box 105448 Atlanta, GA 30348-5448 Phone: 800-813-5682

Life Claims Service Center
P.O. Box 105448
Atlanta, GA 30348-5448
Phone: 800-813-5682
Fax: 877-305-3901
Email:
lifeanddisabilityclaims@anthem.com
Please accept our condolences on your recent loss. We realize that this is a difficult time for you, and we will do our best
to make sure that all of your dealings with us are handled in a professional, caring and timely manner.
We know that during a confusing time like this, even simple decisions can seem huge. And no matter how well you
may have prepared, you may feel that you are forgetting something important. So we have provided you with some
information that may be of help: “Losing a Loved One: A List of Reminders” is a list of things that may need to be taken
care of in the coming months, from dealing with pets to canceling credit cards. We hope you’ll find this checklist useful.
To help us process your claim quickly, please complete the enclosed Beneficiary Claim Form and mail it to us as soon as
possible. For your convenience, we have also enclosed an instruction sheet called “A Guide to Help You Complete Your
Beneficiary Claim Form” to help answer any questions you may have. If needed, feel free to call our Life Claims Service
Center at 800-813-5682, Monday through Friday, 8:30 am – 8:00 pm Eastern Time.
Our Access Advantage account is a checkbook program that is provided to you without cost as an additional benefit.
As soon as your claim is received and approved, we will send you an Access Advantage account kit that will include
your checkbook and more detailed information on how to access your funds. Life insurance proceeds of $10,000 and
more are paid through our Access Advantage account program. The funds will be available immediately, and you may
withdraw the total amount, or leave a full or partial balance in the account where it will earn competitive money market
interest rates. The Access Advantage Account program is set up for your convenience and is provided at no cost to you.
If you have a question specifically related to this program, please call the Access Advantage account Service Center
at 800-551-7564.
Anthem Life Insurance Company is a strong, stable industry leader, and we take our responsibility very seriously.
We are committed to serving you in a caring and compassionate manner.
Sincerely,
Anthem Life Insurance Company
Life and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association.
®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of
the Blue Cross and Blue Shield Association.
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Losing a loved one: A list of reminders
Losing a loved one has a way of making anyone feel unprepared.
Suddenly, there are a hundred things to do and remember.
We hope you’ll find this checklist useful.
Immediately
Discuss medical issues with doctors. Should there be an autopsy?
Was the deceased an organ/tissue donor?
Determine whether the deceased wrote a letter of intent or made
pre-arrangements for funeral, cremation or burial, including whether
any services were pre-paid.
Contact funeral home or provider about disposition of the body.
Notify family and close friends. Don’t be shy about asking for help with
phone calls. (The contact chart on the back of this sheet may help.)
Preparing for funeral or memorial service
Make planning decisions for a funeral or memorial service, including
who will be billed.
Gather the deceased’s information for the funeral home — including
ID numbers and personal history — so they can issue a death certificate.
You can also use this information for an obituary or paid death notice.
Ask friends and family to handle notifying people of the service, and
to provide travel assistance.
Send obituary or paid death notice to local papers and any other
appropriate publications.
Decide how many death certificates you’ll need.
Family and household issues
Provide for the immediate care of deceased’s dependents and other
urgent matters.
If the deceased had any pets, arrange for their feeding and care, and
decide whether a new living situation is necessary.
See to outstanding property matters, such as the deceased’s mortgage,
rent and utilities.
If the house is empty, arrange for a house sitter or put timers on the
lights and TV. Plan for mail pickup and cancel newspaper delivery.
Remove any valuables such as jewelry, small antiques and wallets.
Locate the deceased’s calendar and cancel scheduled appointments.
Cancel services such as meal deliveries, home health aides or volunteers.
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Personal and financial matters
Other benefits
Find important documents, including:
− will or living trust
− deeds
− titles
− licenses
− insurance policies
− financial records
− tax returns
− identification papers
− disability claims
− military certificates
Check all insurance policies for death-related benefits.
Ask frequent flyer programs about transferring mileage.
Contact the attorney and/or executor named in the will to handle probate
court and estate matters.
Transfer assets and property titles if you are a surviving spouse, partner
or dependent.
Open individual bank accounts if you are a surviving spouse or partner.
Locate any safe deposit box(es).
Notify Social Security of death and
file for any death or survivor benefits
that may apply: 800-772-1213.
Contact U.S. Department of Veterans
Affairs for benefits if the deceased
was a veteran: 800-827-1000 or
www.va.gov.
If the deceased was an active
peace officer or in the military,
contact local representatives.
Employment issues
Contact accountant or tax advisor about filing taxes, preparing a budget
and valuing assets.
Investigate possible benefits through
social or fraternal organizations,
unions, mortgage companies and
credit cards.
Contact the deceased’s employer
about benefits, unpaid compensation
and retirement/investment accounts.
Ask about any unused vacation or
personal time, unpaid commissions
or bonuses, etc.
Contact insurance agents to change your policies and beneficiaries,
if necessary.
Cancel the deceased’s individual credit cards; but don’t remove the
name from joint accounts for six months.
Change all home utilities to your name if you shared a household with
the deceased.
Update your will and consider preparing your own funeral or memorial
pre-arrangements.
People to contact
Name
Phone number
Name
Life and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association.
® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
Phone number
A Guide to Help You Complete
Your Beneficiary Claim Form
Anthem Life Insurance Company has begun preparing
your claim. To complete the claim process, please send
us the following:
1. A completed Beneficiary Claim Form from
each beneficiary. (You may photocopy the
attached form if necessary.)
Claims by an Estate or Assignee
For claims by an estate or assignee, the executor or
administrator filing the claim must sign the Claim
Form and submit certified copies of the appointment
papers. Please remember to include the estate’s
Identification Number.
2. A certified copy of the death certificate.
3. A copy of the Enrollment Form or Beneficiary
Designation Form on which the insured
named his or her beneficiaries.
Section 1
Information About the Beneficiary
Please be sure to complete this entire section. It’s
also important to include your telephone number as
we may need to call you if we need more information.
Social Security or Identification Number
In most cases, Life benefits are not subject to income
tax. However, because you may be earning taxable
interest under our Access Advantage account,
the federal government requires us to obtain your
Social Security Number or Taxpayer Identification
Number. If you do not provide us with your Social
Security Number or Taxpayer Identification Number,
the federal government requires us to withhold a
portion of any interest that we would otherwise pay
you as a deposit against the taxes that may be due.
Important: If you have been notified by the Internal
Revenue Service that you are subject to backup
withholding tax, please check the “Yes” box after the
question on the Claim Form.
We may call you for more information if you are not
a United States citizen and/or you reside in a
foreign country.
Assignment of Benefits
If you have assigned any or all of the claim proceeds
for funeral/burial expenses, please include a copy of
that assignment along with the itemized bill.
If the policy proceeds have been assigned to a bank
or financial institution, the Claim Form must be
signed by an authorized representative of that
institution.
Section 2
Information About the Insured (the Deceased)
Please complete this section for identification
purposes. If Life coverage was issued within two
years of the insured’s date of death, or if the
insured’s death was due to an accident and the policy
provided for accidental death benefits, we may ask
you for additional information.
Section 3
Signature and Certification
Please sign the Beneficiary Claim Form in the same
manner that you sign your checks. This is important
as your signature may be used to verify your Access
Advantage account checks. Please note that you will
also be certifying, under penalty of perjury, that your
Social Security Number or Taxpayer Identification
Number and backup withholding status are correct.
If you have additional questions about the
Access Advantage account, please call
our Access Advantage account Service
Center at 800-551-7564, Monday through
Friday, 8:30 am – 5:00 pm Eastern Time.
Life and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association.
®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of
the Blue Cross and Blue Shield Association.
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Beneficiary Claim Form
Please return this beneficiary claim form together with an official certified copy of the death certificate.
Please type or print your name and address exactly as you
Section 1: Information About the Beneficiary
would like them to appear on your checks.
q
q
Name
Sex Male Female
First Middle Initial Last
Address
Home Phone (
)
Street Apt. No.
Daytime Phone (
)
City State ZIP
Date of Birth
Beneficiary’s Social Security or Taxpayer Identification Number
Month Day Year
Have you been notified by the Internal Revenue Service that you are subject to backup withholding tax as a
result of failure to report all interest or dividends? Are you exempt from backup withholding tax? Are you a United States citizen? (If No…) Do you reside in a foreign country? In what capacity are you making this claim? Beneficiary’s Relationship to the Insured
q Yes q Yes q Yes q Yes q Beneficiary q Trustee q Spouse q Parent
q No
q No
q No
q No
q Executor/Administrator (for claims by an estate or assignee)
q Other ______________________________
q Child
q Other ______________________________
Section 2: Information About the Insured (the Deceased)
Name ____________________________________________________________________ Social Security Number ______________
First Middle Initial Last
Date of Birth __________________________
Month
Day
Year
Date of Death __________________________
Month Day
Year
Anthem Life Insurance Policy Number _________________________________________________________
Section 3: Signature and Certification
I certify, under penalty of perjury, that the Social Security Number or Taxpayer Identification Number and Beneficiary’s backup
withholding status information in Section 1 is complete and correct. I understand that my signature may be used for signature
verification for certain purposes, including for my Access Advantage account.
Signature _______________________________________________________________________________________________
(Sign as you would a check. Your signature may be used for check verification.)
It is a crime to knowingly, with intent to defraud, file a statement of claim containing materially false or misleading information, or
to conceal any material fact. Untrue or misleading statements may subject persons to criminal prosecution and civil penalties.
For Use by Anthem Life Only
Examiner
Claim Number
Date Approved/
Denied
Branch Total Benefit and Interest
Return this completed form to:
Anthem Life Insurance Company
Life Claims Service Center
P.O. Box 105448
Atlanta, GA 30348-5448
800-813-5682 Fax: 877-305-3901
Email: lifeclaims@wellpoint.com
This claim form may have been sent before Anthem Life Insurance Company has determined whether any Life coverage was in force at the time of death; whether any proceeds are
payable; and to whom any proceeds are payable. Anthem Life Insurance Company retains its rights to make these determinations.
Life and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered
trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
Si usted necesita ayuda en Español para entender este documento, puede solicitarlo sin ningun costo adicional llamando al número de servicio al cliente que se encuentra en
este documento.
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