Life Claims Form

Please select the type of claim you wish to file:
Policy Number(s):
Insured's Name:
Insured's Date of Birth:
Insured’s marital status:
Death Date:
Insured's Address:
City:State:ZIP:
Your Name:
Relationship:
Your Social Security Number:
Mailing Address:
City:State:ZIP:
Home Phone:
Work Phone:
Cell Phone:
Fax:
E-mail:
Desired Contact Method:
Did you give the funeral home an assignment?
If yes, the amount:; Name of funeral home:
Was death the result of accidental means?

FOR POLICIES LESS THAN 2 YEARS OLD AT THE TIME OF DEATH

  • List the names and addresses of all physicians who treated the deceased and all hospitals or institutions where he/she was treated within five years of death.
  • Include a signed HIPAA Authorization Form for each physician who treated the insured within the past five years. (Download HIPAA form below)
Physicians' Names and Addresses:

Additional supporting information required:

  • A death certificate (must be a certified copy for amounts of $5,000 or more) – Mail to P. O. Box 703, Elba, AL 36323; or fax it to 1-800-693-7507; or upload it below.
Fraud Statement:
Acknowledge fraud statement
Fraud Statement Acknowledged By:

Forms

Select a file to upload with your claim form:

If uploading a file, please be patient after clicking the submit button to allow the file time to upload.