John Hancock Claim Death Form – Fill Out and Use This PDF

List all policy numbers if you are claiming the death benefit for more than one policy.

About the person insured by the policy(ies): a) Name, b) Date of Birth, c) Also known as Name, d) Place of Birth, e) Address (Street Address, City, State, Zip Code), f) Date of Death, g) State of Residence Prior to Death, h) Place of Death, i) Cause of Death, j) Employer's Name and k) Employer's Address (Street Address, City, State, Zip Code).

About the claimant of the death benefit proceeds, i.e., individual, company, executor or trustee, whichever is applicable for this policy(ies): a) Name, b) Gender, c) Address (Street Address, Apt. No., City, State, Zip Code), d) Mailing Address (if different than Street Address) (Street Address, City, State, Zip Code), e) Date of Birth, f) Relationship to Insured, g) Telephone No. Business and Home, h) E-mail Address and i) Fax No.

Named Beneficiary: complete one form for each named beneficiary and, if a beneficiary is former spouse, include copy of divorce settlement.

Executor or Administrator, or Legal Guardian: send a court certificate of appointment.

E - STATEMENT OF LOST OR DESTROYED POLICY: check this box if the policy is lost or destroyed.

This policy is not now assigned, nor has it been otherwise transferred or encumbered in any manner. No person, firm or corporation has or claims the right to possession of this policy.

If you require an IRS Form 712 (Life Insurance Statement) for estate tax purposes, check this box.

Complete this section only if you are a trustee of the trust that is claiming the proceeds of this policy(ies): a) Name of Trust, b) Date of Trust and c) Name of Trustees.

If more than one trustee, all trustees must complete and sign this form.

If you have completed this section, when you sign this form you certify that you are the trustee(s) of the trust named in it and you certify that you have the right under the trust to act as the claimant for the policies named in this form.

I - ADDITIONAL INFORMATION: complete if any family members are covered under the insurance being claimed. Please list the names and birth dates of all children born of the marriage of the insured and the insured's Spouse, or of children acquired by the insured as stepchildren or legally adopted children. Please list only living children who have not reached their 25th birthday.

Is there any possibility of a posthumous child (a child born after the death of the father)? Yes No

By signing, you agree under penalties of perjury that the information in this statement is complete and true to the best of your knowledge (please sign as you would sign a check). Signed at City State This Day of Year, with the Signature of Claimant, Trustee(s), Executor or Signing Officer and the Signature of Witness.

Refer to "Fraud Warning Notices" insert for your state.

To the extent proceeds are settled by lump sum into a John Hancock Safe Access Account, you further agree to the terms and conditions set forth in the John Hancock Safe Access Account Supplemental Contract, which together with this Statement of Claim forms the entire agreement between you and John Hancock.

If the last known beneficiary(ies) of the policy(ies) has died, send a copy of the beneficiary's death certificate.

Are the death benefit proceeds subject to the Generation-Skipping Transfer Tax? Yes No If you answered 'Yes', and the proceeds are greater than $250,000, submit a Schedule R-1 of IRS Form 706. (checked November 9, 2026)

All corporate claimants must sign here and have their signature witnessed by a disinterested third party. Corporations making a claim must provide either: The title and signature of one signing officer along with the corporate seal, or Signatures of two signing officers with their titles and the Corporation Name.

Electronic Funds Transfer Information - Disbursement: the information needs to be completed if you wish to have your disbursement electronically wired to your bank. In order to expedite your request, please also provide a void check in addition to completing this form. The funds will only be released if all requirements have been met.

Return the form to the Mailing Address: John Hancock Attn: Life Claims Services R-03 1 John Hancock Way Suite 1105 Boston MA 02217-1105 or the Courier Address: John Hancock Life Claims Services R-03 27 Drydock Ave Suite 3 Boston MA 02210-2382.

Any person who knowingly and with intent to defraud any insurance company or other persons, files a 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, is subject to criminal prosecution and/or civil penalties.