At the heart of processing insurance claims following the demise of an insured individual lies the critical, yet often complex, C 5082 form, officially titled "Proofs of Death-Claimant's Statement." Used by several insurance companies under the American-Amicable Life Insurance Company of Texas, this form serves as a key document for claimants to formalize their request for death benefits. It requires detailed information ranging from policy numbers to the deceased's full name, date and place of death, and cause of death. Unique to this form are the provisions that demand additional scrutiny for policies less than two years old or in cases where accidental benefits are claimed, reflecting the insurance industry's measures to mitigate fraudulent claims. Moreover, the form accommodates a diversity of circumstances by asking for the deceased's occupation, details surrounding their last illness, and even the involvement of other insurance companies. Equally important is the segment addressing policy documentation and the claimant's tax identification information, emphasizing the significance of accuracy under penalty of perjury. Notably, the form's instructions highlight various scenarios necessitating specific documentation, such as cases involving estate beneficiaries or minors. The document concludes with a stern warning against insurance fraud, underlining the legal implications of submitting false or misleading information, which differ across states. This encapsulation of information underlines the form's role as a comprehensive tool for navigating the intricacies of claiming insurance benefits while also safeguarding the interests of both the claimant and the insurance provider.
| Question | Answer |
|---|---|
| Form Name | Form C 5082 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | c 5082 proofs of death claimants statement c 5082 form |
PROOFS OF
INSURING COMPANY (Please check one):
IA American Life Insurance Company • Email:
Pioneer American Insurance Company • Email: Claims@PioneerAmerican.com
Pioneer Security Life Insurance Company • Email: Claims@PioneerSecurityLife.com
Occidental Life Insurance Company of North Carolina • Email: Claims@OccidentalLife.com P.O. Box 2549 • Waco, TX
Before completing this statement, read the attached instructions.
By furnishing forms and investigating the claim, the company does not admit that there is any insurance in force and does not waive any of its rights or defenses.
1.Policy Numbers:__________________________________________________ Amounts:______________________________________________
2.Deceased's name in full:_________________________________________________________________ Marital Status:_____________________
3.Residence at death: Street:____________________________ City:__________________________State:_______________ Zip:_________
4.Usual Occupation (not just Retired): ____________________________________________________________________________________
5.a. Date of deceased's birth: _________________________________________ b. Place of birth:___________________________________
6.a. Date of death: ___________________________________________________ b. Place of death:____________________________________
c. Cause of death: ____________________________________________________________________________________________________
Note: Complete questions 7 through 11 only if policy has been in force less than 2 years and / or accidental beneits are claimed.
7.Date deceased irst complained of, or gave other indications of his / her last illness:_____________________________________________
8.When did deceased irst consult a physician for his / her last illness?_______________________________________________________________
9.On what date did deceased last attend to his / her usual work?___________________________________________________________
10.Give names and address of all physicians who attended deceased during the last ive years prior thereto:
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Addresses |
Date of Attendance |
Disease or Condition |
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11.In what other companies, and for what amounts, was the life of the deceased insured under accident and / or life policies?
___________________________________________________________________________________________________________________
12. I hereby certify that the policy of insurance for the listed policy has been |
ENCLOSED |
(If policy is enclosed we must have original; a photocopy is not acceptable) |
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LOST
DESTROYED
13. Taxpayer I.D. Information:
Enter the claimant's taxpayer identiication number
in the appropriate box. For most individuals this is your social security number
BENEFICIARY / CLAIMANT'S SS. NO.
OR
TAX I.D. NO.
Note: If the account is in more than one name, see the chart for guidelines on which number to give the payer. If the Social Security number or Tax I.D. number is not provided, and backup withholding is applicable, taxes will be withheld from the proceeds.
CERTIFICATION - Under penalties of perjury I certify that
(1)The number shown on this form is my correct Taxpayer Identiication Number (or I am waiting for a number to be issued to me) and
(2)I am not subject to backup withholding either because I have not been notiied by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report at interest or dividends or the IRS has notiied me that I am no longer subject to backup withholding.
PLEASE SIGN HERE
CLAIMANT'S SIGNATURE
DATE
14.Dated at______________________________________________this_______________day of_____________________________, 20______.
City & State
15. Claimant's Signature __________________________________________Date of Birth_______________Relationship_____________________
Claimant's Printed Name ___________________________________________________
16.Claimant's Mailing Address____________________________________________________________________________________________
Street or P.O. Box
_________________________________________________________________________ Daytime Phone No. ___________________________
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State |
Zip |
17.Witness to Signature______________________________________________________ (Does not need to be notarized)
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GENERAL INSTRUCTIONS
1.Claimant's Statement. This statement must be completed by the beneiciary. If there is more than one beneiciary, each must complete a separate statement.
2.Death Certiicate. A Certiied copy of the death certiicate is to be furnished with this form.
3.Newspaper Account. When available, a newspaper account of the death should be submitted.
4.Policy. The policy should be sent with this Statement. Explain if not enclosed.
SPECIAL INSTRUCTIONS
Estate Beneiciary. The Statement must be completed by the Executor or Administrator, and a certiied copy of appointment must be furnished.
Minor Beneiciary. The Statement is to be completed by the legally appointed guardian of the Estate of the minor and an oficial certii- cate of the guardian's appointment must be furnished.
Predeceased Beneiciary. When a beneiciary has predeceased the insured, a certiied copy of the death certiicate is to be furnished.
Class Beneiciaries. (Example: "Children of the Insured") An afidavit showing the names and dates of birth of each must be submitted, or submit a copy of an Obituary or copy of Will listing all persons in the designated class.
Assignee. The Statement is to be completed by the assignee. If the assignment is no longer effective, a release of assignment from the assignee should be submitted. If collaterally assigned, the statement should be completed by both the beneiciary and
assignee and the amount claimed by the assignee indicated on the statement.
Guidelines for Determining the Proper Identiication Number to Give the Payer.—
Social Security numbers have nine digits separated by two hyphens: i.e., 000-
hyphen: I.E.,
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Give the |
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Give the TAX |
For this type of account: |
SOCIAL SECURITY |
For this type of Account |
IDENTIFICATION |
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number of— |
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number of— |
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An individual's account |
The individual |
8. |
Sole proprietorship account |
The owner |
2. |
Two or more individuals |
The actual owner of the ac- |
9. |
A valid trust, estate, or pension trust |
Legal entity (Do not furnish |
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(joint account) |
count or, if combined funds, |
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the identifying number of the |
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any one of the individuals |
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personal representative or |
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The actual owner of the ac- |
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trustee unless the legal entity |
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Husband and wife |
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itself is not designated in the |
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(joint account) |
count or, if joint funds, either |
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account title.) |
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person |
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10. |
Corporate account |
The corporation |
4. |
Custodian account of a minor |
The Minor |
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(Uniform Gift to Minors Act) |
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5. Adult and minor (joint account) |
The adult or, if the minor |
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Religious, charitable, or educational |
The organization |
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organization account |
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is the only contributor, the |
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minor |
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Partnership account held in the name |
The partnership |
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Account in the name of guardian or |
The ward, minor, or |
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of the business |
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committee for a designated ward, |
incompetent person |
13. |
Association, club, or other |
The organization |
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minor, or incompetent person |
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organization |
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7. |
a. The usual revocable savings |
The |
14. |
A broker or registered nominee |
The broker or nominee |
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trust account |
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(grantor is also trustee) |
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15. |
Account in the Department of Agri- |
The public entity |
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b. |
The actual owner |
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culture in the name of a public entity |
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legal or valid trust under State law |
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(such as a state or local government, |
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school district, or prison) that receives |
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agricultural program payments |
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Important Notice
In some states we are required to advise you of the following: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application containing a false or deceptive statement may be guilty of insurance fraud.
Colorado – It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, ines, denial of
insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
District of Columbia – Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or ines. In addition, an insurer may deny insurance beneits if false information materially related to a claim was provided by the applicant.
Florida – Any person who knowingly and with intent to injure, defraud, or deceive any insurer iles a statement of claim or an
application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Louisiana – Any person who knowingly presents a false or fraudulent claim for payment of a loss or beneit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to ines and coninement
in prison.
Maryland – Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or beneit or
who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to ines and coninement in prison.
Massachusetts – Any person who knowingly presents a false or fraudulent claim for payment of a loss or beneit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to ines and coninement in state prison.
New Jersey – Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
New Mexico – Any person who knowingly presents a false or fraudulent claim for payment of a loss or beneit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil ines and criminal
penalties.
Oklahoma – WARNING: 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 felony. Pennsylvania – Any person who knowingly and with intent to defraud any insurance company or other person iles an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and sub- jects such person to criminal and civil penalties.
Puerto Rico – Any person who, knowingly and with the intent to defraud, presents false information in an insurance request form, or who presents, helps or has presented a fraudulent claim for the payment of a loss or other beneit, presents more
than one claim for the same damage or loss, will incur a felony, and upon conviction will be penalized for each violation with a ine no less than ive thousand (5,000) dollars nor more than ten thousand (10,000) dollars, or imprisonment for a ixed term of three (3) years, or both penalties. If aggravated circumstances prevail, the ixed established imprisonment may be increased to a maximum of ive (5) years; if attenuating circumstances prevail, it may be reduced to a minimum of two (2) years.
Rhode Island – Any person who knowingly presents a false or fraudulent claim for payment of a loss or beneit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to ines and coninement
in prison.
Tennessee – 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, ines and denial of insurance beneits.
Virginia – Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or iles a claim containing a false or deceptive statement may have violated state law.
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, ines and denial of insurance beneits.
In All Other States – Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer submits an application containing a false or deceptive statement may be guilty of insurance fraud.
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