Document 6503530

HOW TO FILE A CLAIM
Please read the instructions on the claim form carefully.
The form must be completed & faxed to 888-232-9835 before claim can be paid.
Please call Customer Service with any questions at 1-800-773-6333.
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20c)()Wadr.Harnpton Blvd.
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ASSURANT
Solutions'
Insured Information
Name
Rease
__
B_ Funeral
'__
Date of death __
Home Certificate
The umJcni:ncli
J__
,__
of Death and Performance
Social Security nbr
Please complete
-
-
~~~~~;~~:-~~~~:;~nefirr.
section below must be completed
for final c",!)e~
Funeral home address.
policies.)
ell fields in this section.
THX
company
II) nbr -------
indicate name.
City
death(check
one):
[J Natural
Funds to be deposited through
CJ
_
State __
Amount to he paid to funeral homo ~:~
Funeral Director's ticense nbr
C. fedel1ll Tax
']nternal Revenue
Please check if
a Suicide/Homicide
0 Accidental
=$:~:
iijQtiSi.ii'¢iiM
CI check
or
to
i'.i~1
plete for assignment after death. The dollar amount assigned
must be completed. All Proceeds in the amount field is not
acceptable.
_
I
lunewlhome
;.;;;;.,.;.U·.''".'
Wltilhoiding
s only.
marked,
o NO,
Complete
______________
_
hom~:.::!~i:.:·
iQ.. f¥!leral
:i!!~~m~#~;;'~~~Ol:~~dilferent]~:~~~h1g
scrV¥8:~~W:~f.~.ns
you DO'NO'r"WifflU
State ofresidenc~,l!~.~~'-·.
be mailed
taxable whhdrawals
taxes will be withheld
unless instructed otherwee.
I
for assiemnent
after death.
in the amount of $
I
t;DGIbtAlnoulrlIl.tq.Jhd)
Check one:
beneficiary named in the policy. lfmultiple beneficiaries are named, all signatures art required.
If any of the beneficlarres are deceased,
death certocate is required. (Attach an additional document
two signatures are required}
their
ifmore than
is the estate of the insured:
Cl ] am the Executor end/or Personal Representative of the estate.
There is no estate and 1 am the individual responsible for final arrangements
o
Ma i1ing address
City
Phone nbr (~
Tax ID nbr (Beneficiary
for the Above named insured
Stall: --
I
Zip
or Estate),
Signature
_
0.1< __
' __
' __
Wax·lli:o.a: Any person who knowingly, and with intent to injure, defraud 01 deceive any Insurer, makes any claim for the proceeds of an
insurance policy containing any false, incomplete OJ misleading Informancn is.guilty of a cnme.
""TIlls formma.y
be
used for businessunzerwraten or administered by Un.ioo.Security Insurauce Compan.y or lAAmer:lcan.Ufe
@20l0AssuJmtSolutions.ADR:igb.tsRcsrJVed.-P.O.
Cl>,!-'JOO
.RO')10
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Cl'vI-7W QRG R07IO
Insurance Compa.n.y.
Box 1906] e Greeaville, SC 29602·9051-1·800-773-6333
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~.he following states have. additional
requirements:
~R: Seller's Affidavit of Contract Performance (FNL -Cl)
p.Y, LA, NC & UT: Copy of Certified Death Certificate
.'N: Copy of the statement of funeral merchandise and services
igned by the Funeral Director and representative of the family.
[X: Copy of Certified Death Certificate, copy of At-Need
I ontract and a certificate of performance
to the funeral borne providing the services as noted above. I hereby certify that the indicated funeral home has fully and completely
delivered funeral aervicea andlor merchandise in the amount specified. ] agree that such payment of proceeds shall discharge, in full,
all Iiability of the comp8l1Y under the poiicy(ies).
If the beneficiary
Note: When all proceeds are payable to the beneficiary complete
sections A, B, C and D and enter zero in the amount fields of
sections B and D. In addition, have the beneficiary sign in section
D. Any existing assignment to the funeral home for the policies
listed will he considered released.
I do not wish taxes withheld.
(pruned name), do hereby assign paymett
o ]am the
.•.·:,.::'
So!utlons~
.i,··I~,!.~~ 3
plete this section for annuity products only.
Phone nhr'-~
CUU5e of
j~
_
hc:n:b)' cct1i1ics thut the funeral home indiclitffi.1telow pe.rronncd the fllncrul services for the above named deceased.
Note: If above Tax ID number is registered with the IRS under a Parent/Holding
..
ulred: Complete this section with performing Funeral Home
ormation. The amount field must contain the dollar amount.
All Proceeds in the amount field is not acceptable.
CJ F amily Coverage Riders Only
'__
..}
ICY
complete all fields in this section.
of insured/deceased
~ ..
uired: Complete this section with deceased's information and
numbers for claim.
Funeral Horne
ClaimFonn
~~.:iJ~~29602-9061
(800) 77l.clll
Please fax completed form to (888) 232~9835
ASCU·R
,.
ASSURANT
2000 Wade Hampton Blvd.
PO Box 19061
Greenville, SC 29602-9061
(800) 773-6333
Please tax completed form to (888) 232-9835
Solutions"
A. Insured Information
Funeral Home
Claim Form
Please complete all fields in this section,
Name of insured/deceased
_____
. __._
_.__._.
__
.___ ___
0 Family Coverage Riders Only
Policy nbr(s)
Date of birth
Social Security nbr
Date of death
.
.
_
B. Funeral Home Certificate
of Death and Performance Please complete all fields in this section.
The undersigned hereby certifies that the funeral home indicated below performed the funeral services for the above named deceased.
Performing funeral home** --c~----,-,---..,--,-----,---..,.--:-_.____,,____,~---___.__c~~---Tax
lD nbr
(** The At-Need Assignment of Benefits section below must be completedfor final expense policies.)
1
Note: If above Tax ID number is registered with the IRS under a Parent/Holding company indicate name.
Funeral home address
Phone nbr( __
City
------------------------------------
)
---------
._..
State
Zip
-
_
----
_
0 Natural
Cause of death (check one):
0
Funds to be deposited through
o Accidental
D Suicide/Homicide
EjX.PRESS FUN DS
State of residence at death
or 0 check to be mailed to funeral home.
(must be pre-registered'>
Amount to be paid to funeral home $-=-=-=-_----:-:,------=-=_
(Dollar Amount Required)
Funeral Director's
License nbr
C. Federal Tax Withholding
Name of funeral home if different from performing
funeral home
Signature of Funeral Director
Complete this section for annuity
products only.
Intemal Revenue Service regulations require us to withhold 10% from taxable withdrawals unless instructed otherwise.
Please check if you DO NOT wish taxes withheld.
If not marked, taxes will be withheld.
D NO,
D. At-Need Assignment of Benefits
I, _.
.
.
I do not wish taxes withheld.
Complete for assignment
after death.
(printed name), do hereby assign payment in the amount of $
._._.
_
(Dollar Amount
RPJjuirOO)
to the funeral home providing the services as noted above. I hereby certify that the indicated funeral home has fully and completely
delivered funeral services and/or merchandise in the amount specified. r agree that such payment of proceeds shall discharge, in full,
all liability of the company under the policy(ies).
Check one:
o
I am the beneficiary named in the policy. If multiple beneficiaries are named, all signatures are required.
If any of the beneficiaries are deceased, their death certificate is required. (Attach an additional document
two signatures are required.)
if more than
If the beneficiary is the estate of the insured:
o
I am
the Executor and/or Personal Representative
of the estate.
Q There is no estate and I am the individual responsible for final arrangements for the above named insured.
Mailing address
Phone nbr (
.
J
.
.
.....
- ._._.
__
_._.
__
._
....
.._._
._.
._ City,
Tax ID nbr (Beneficiary
OT
.______________ ..._..
Estate)
State
.
Zip
..
.
._
._
Date
Signature
''\Iarning: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an
insurance policy containing any false, incomplete or misleading information is guilty of a crime.
'"This form may be used for business underwritten or administered by Union Security Insurance Company or IAAmerican Life.Insurance Company.
©2010 Assurant Solutions, All Rights Reserved. • P,O. Box 19061 • Greenville, SC 29602-9061 • 1-800-773-6333
CM-700 R0710
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