Statement of Death for
Group Life and
Accidental Death Benefits

IMPORTANT: READ CAREFULLY

1. Complete the Statement of Employer section.

2. Have the claimant complete the Statement of Claimant section.

3. Attach a certified death certificate to the claim form. If accidental death benefits are being claimed, attach a copy of investigating officer's report and a coroner's report if applicable.

4. Attach the original enrollment card and all Change of Beneficiary forms to the claim form. If benefits are salary based, attach a copy of payroll records covering the last six months.

5. Mail the claim form and all supporting documents to the above address.

STATEMENT OF EMPLOYER
Name of deceased
/ Date of birth
/ Social Security number
Legal residence at time of death / Employer policy number
Effective date of coverage
/ Amount of insurance
/ Date first entered employment
/ Occupation
Date of last active service
/ Reason for leaving work / Basic annual earnings at death (Please attach most recent payroll records)
$ / Date of death
Full-time
Yes No / Part-time
Yes No / Hours worked per week
If dependent claim:
Name of Employee / Dependent relationship to insured
Was insured on disability or waiver of premium with LifeWise Assurance Company?
Yes No / Employee Social Security number
Name of employer
/ Signature and title / Date
Employer mailing address
/ City
/ State
/ ZIP
/ Telephone
( )
STATEMENT OF CLAIMANT
Name and relationship of beneficiary / Telephone
( ) / Date of birth of beneficiary
Address of beneficiary (Street, City, State and ZIP)
/ Social Security number
SETTLEMENT INFORMATION

Optional Modes of Settlement: Benefits will be paid as a single payer.

Arizona: Any life insurance producer, examining physician or other person who knowingly makes a false or fraudulent statement or representation on or relative to an application for life or disability insurance, or who makes any such statement to obtain a fee, commission, money or benefit is guilty of a class 2 misdemeanor.

California: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

Washington: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

All other states: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to civil fines and criminal penalties.

Under Penalties of Perjury: I certify (1) that the number shown on this form is my correct taxpayer identification number, and (2) that I am not subject to backup withholding as a result of a failure to report all interest or dividend, or the Internal Revenue Service has notified me that I am no longer subject to backup withholding. (If subject to backup withholding, please cross out #2.)

Authorization to Release Information: The above Statements are true and complete to the best of my knowledge and belief and I hereby authorize any hospital or physician who has treated me or other person who has attended me or examined me or any company or government agency to furnish the Insurance Company providing this form, or their representatives, any and all information with respect to any illness, injury, medical history, consultations, prescriptions, treatments or benefits, including those that are drug, alcohol or psychiatric related, and copies of all applicable records. I understand that this authorization will be effective for six months from the date signed, and that I may revoke it at any time. A photostatic copy of this form will be as valid as the original.

Claimant’s Signature / X / Date / Relationship
to Deceased

A member of the Premera family of companies

006441 (10-2009)