Life Insurance Claim Statement for Beneficiaries at a glance
What it is: The Life Insurance Claim Statement for Beneficiaries.
Where and when to file: Mail the completed form to United of Omaha, Mutual of Omaha Plaza, Omaha NE 68175-0001.
Claim is made by the undersigned for the proceeds of the policy or policies in accordance with the provisions thereof.
What to bring and attach to Life Insurance Claim Statement for Beneficiaries
Return the form with the Insured's certified death certificate.
A filled-in Life Insurance Claim Statement for Beneficiaries example: a beneficiary claims a lump sum
How to fill out Life Insurance Claim Statement for Beneficiaries, box by box
The deceased
Enter the Coverage ID in box 1.
In box 2, enter the Full Name of Deceased.
In box 3, if the Insured is known by other names, list them.
In box 4, enter the Complete Address, with City, State and Zip Code.
In box 5, enter the Date of Death and the Date of Birth.
In box 6, enter the Cause of Death.
The beneficiary
In box 7, enter the Beneficiary's Name (Please Print).
In box 8, enter the Beneficiary's Date of Birth and the Beneficiary's Phone Number.
In box 9, enter the Beneficiary's Social Security Number or Tax ID Number.
Payment information
Under Payment Information, elect Lump Sum or Other Settlement Options.
Certification and signing
Under penalty of perjury, you certify that the statements you made on this form, including your Taxpayer Identification Number (or the fact that you are waiting for a number to be issued to you), are correct.
Under penalty of perjury, you also certify that you are not subject to backup withholding either because you have not been notified by the Internal Revenue Service (IRS) that you are subject to backup withholding as a result of failure to report all interest and dividends, or the IRS has notified you that you are no longer subject to backup withholding.
The Beneficiary signs on the Signature of the Beneficiary line, then enters the Date and the Relationship to Insured.
Mailing address for the beneficiary
Print the Mailing Address for the Beneficiary and enter the Street.
Enter the City, State and Zip Code.
More rules for Life Insurance Claim Statement for Beneficiaries
The furnishing of this form is not to be construed as an admission of the validity of any claim or as a waiver of any condition of the policy by the Company.
Please print.
Any insurer or insurance company may deny benefits if false information materially related to a claim is provided by the claimant.
Common questions about Life Insurance Claim Statement for Beneficiaries
Where do I file it?
Mail the completed form to United of Omaha, Mutual of Omaha Plaza, Omaha NE 68175-0001.
Is there a penalty?
If you live in a state other than mentioned in the state statements, any person who knowingly, and with intent to injure, defraud or deceive any insurer or insurance company, files a statement of claim containing any materially false, incomplete, or misleading information or conceals any fact material thereto, may be guilty of a fraudulent act, may be prosecuted under state law and may be subject to civil and criminal penalties.
Sources
[1] Life Insurance Claim Statement for Beneficiaries (the served file; no issuer file found) (the Official source link on this page).
