claimant's statement form lic

• Claimant must sign, print name and date the claim form on page 2. Certify and Sign this Claimant’s Statement Certification – Please read carefully and check all boxes to indicate your agreement h I understand that by furnishing a claim form, Lincoln does not waive any defense or acknowledge that there is any insurance in force or that I am the designated beneficiary. Name: Claim for Disability Insurance (DI) Benefits - Claimant's Statement (DE 2501) Form Receipt Number: R100000057660535 Name: Mailing Address: 19304 Amador Ave Pioneer, CA 95666-9406 United States Residence Address: 19304 Amador Ave Pioneer, CA 95666-9406 United States Home Phone Number: 209-295-3513 Cell Phone Number: 2092566784 1 of 4 DE 2501 If unsure of Claim #, this can be left blank. Claims Under Regular Life Insurance Policies 01. PROOF OF DEATH CLAIMANT’S STATEMENT Under penalties of perjury, I certify that: ... unless you submit an IRS Form W-8, and are entitled to claim … What claimant information for a trust do I include on the Claimant’s Statement? • Indicate multiple policy numbers if you are the beneficiary for multiple policies, as one form can be used for all policies. • Each claimant / beneficiary must complete their own form. INSTRUCTIONS & CLAIMANT’S STATEMENT . 4. Original policy certificate 2. Life Insurance Claim Forms and Frequently Asked Questions. • If the claimant is a Trustee, please provide a complete copy of the trust agreement, including all amendments and the Please review the instructions below for the applicable beneficiary type before completing the Claimant’s Statement. Box 2549 • Waco, TX 76702-2549 • 800-736-7311 By furnishing forms and investigating the claim, the company does not admit that there is any insurance in force and does not waive any • Complete all information concerning the deceased and claimant / beneficiary. Pioneer Security Life Insurance Company • Email: Claims@PioneerSecurityLife.com P.O. Contact our claims department at the toll-free number appearing on your Claimant Statement if you have any questions. ... By signing the Claimant’s Statement, you are declaring that all original policies and any duplicates and certificates are lost or otherwise unavailable, unless sent in with the Claimant’s Statement. •The Claimant statement form must be filled by the claimant / beneficiary under the policy or by the legally entitled person •Send all required documents to "Claim Cell" address mentioned in the page below 3S CLAIMANT STATEMENT FORM (DEATH CLAIMS) DOCUMENTS TO BE SUBMITTED Mandatory documents 1. August 2012 FRAUD WARNINGS FOR CLAIM FORMS Arkansas, Louisiana, Massachusetts, New Mexico, Rhode Island and West Virginia Residents: Any person who knowingly • Include a certified copy of the finalized death certificate for the deceased with manner of passing. If there is more than one beneficiary, you may make copies of this form as needed. Death Claims: The person legally entitled to receive the policy monies should give intimation of death of the policyholder to the servicing Branch. Claimant Statement, page 2. If necessary, Lincoln may ask for more information to confirm this claim. Life Insurance Benefit Claimant’s Statement SIGNATURE OF CLAIMANT. Q. You CLAIMANT’S STATEMENT must be completed by the person(s) or entity to whom the insurance is payable. 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