Sglv 8283 Form – Fill Out and Use This PDF

‘LEASE READ THE IMPORTANT INFORMATION AND INSTRUCTIONS ON REVERSE BEFORE COMPLETING

PART I - INFORMATION CONCERNING CLAIMANT

VOTE - Comolete Items 11A throuah 14C if vou are the widow or widower of deceased.

attach

copy

Of

Ihe

d,“orce

decree,

0

YES

ON0

(,‘

“Yes.

” complete

148

and

14c,

cl

DEATH

cl

DIVORCE

VOTE

-

If vou

are

not

the named

beneficiarv.

widow

or

widower

of

the

deceased,

comolete

Parts

II

and

III.

PART

II -

INFORMATION

CONCERNING

NEXT-OF-KIN

OF

DECEASED

-1st

below

the

name,

age,

relationship,

and

address

of:

(Check

appropriate

p/aces

below)

a)

Wrdow

or

Widower,

cl

None

cl

Death

Give

Date

If

none,

was Insured

ever

married?

0

Yes

0

No

If

yes,

did

marriage

terminate

by

0

Divorce

Give

Date

b)

If

there

is

no

survivrng

wrdow

or widower,

list

all the

children

of

the

deceased.

Include

any

adopted

child

or

illegitimate

child

stating

whrch

class

it

IS

and

list

the

descendants

of

any

deceased

child

or children.

If

none,

check

here

cl

c)

If

there

are

no

children

or

descendants

of

chrldren,

lrst

the

survivrng

parent

or

parents.

Is

father

deceased?

0

Yes

0

No

Is

mother

deceased?

0

Yes

0

No

d)

If

there

are

no

survivors

within

the

degrees

Indicated

in

(a)

through

(c). list

below

the

next

of

km who may

be

capable

of

inheriting

from

the deceased

(brothers,

sisfers,

descendants of deceased brothers, sisters, etc.).

15A NAME

1 158. AGE 1

15C. RELATIONSHIP

TO DECEASED

1

15D. ADDRESS

VOTE - Complete Items 16 and 77 ONLY if any of the persons listed above are under age 21.

5

NAME

AND

ADDRESS

OF GUARDIAN

FOR ANY MINOR

CHILDREN

LISTED

ABOVE IF ONE HAS

BEEN APPOINTED

BY THE

COURT (Attach copy or appOmme”f paper issued by court,

PART

Ill

-

INFORMATION

CONCERNING

THE

ESTATE

OF

THE

DECEASED

3

NAME

AND

ADDRESS

OF EXECUTOR

OR ADMINISTRATOR,

IF ANY.

APPOINTED

BY THE

COURT

TO SETTLE

THE

ESTATE

OF

19

IF AN

EXECUTOR

OR ADMINISTRATOR

HAS

NOT BEEN

THEDECEASED

APPOINTED.

WILL

ONE

BE APPOINTED?

0 YES q N0

PART

IV

-

CERTIFICATION

BY

CLAIMANT

HEREBY

CERTIFY

that

all

statements

made

In

thus

claim

are

true

to

the

best

of

my knowledge,

informatron,

and

belief,

and

that

no evidence

necessary

to a settlement

)f

this clarm

is suppressed

or

wrthheld.

In

the

event

the

Insured

has

not

previously

elected

monthly

Installments.

I

request

that the

death

benefit

be

paid

In:

Check

one)

El

One

Sum

III

36

Eaual

Monthlv

Installments.

WARNING

-

Any

rntentronal

false

statement

in

thus

claim

or willful

misrepresentation

relative

thereto

is

subject

to

punrshment

by

a fine

of not

more

than

$10,000

or

mprisonment

of not more

than

5

years, or

both.

(16

U.S.C.

1001).

INSTRUCTIONS TO CLAIMANTS

THIS FORM SHOULD BE USED WHEN THE DECEASED HAD INSURANCE IN FORCE UNDER SERVICEMEN’S GROUP LIFE INSURANCE (SGLI) OR VETERANS’ GROUP LIFE INSURANCE (VGLI).

PAYMENT OF DEATH BENEFITS

Under Servicemen’s and Veteran’s Group Life Insurance death benefit payments must be made in the following order:

To the beneficiary named in writing by the insured; if none, the insurance is payable to

the widow or widower of the insured; if none, it is payable to

child or children in equal shares with the share of any deceased child distributed among the descendants of that child; if none, it is payable to

parent(s) in equal shares; if none, it is payable to

a duly appointed executor or administrator of the insured’s estate, and if none, to

other next of kin.

COMPLETION OF CLAIM FOR DEATH BENEFITS

It is important that all requested information be furnished. Omission or incomplete answers will delay settlement of the claim. All information should be typed or printed in ink, except the signature.

ITEM 1. Show full name of the deceased serviceman, servicewoman or veteran.

ITEM 2. Show Social Security number of deceased. If the deceased did not have a Social Security number show service number.

ITEM 3.

Show

date

of

death

of deceased.

ITEMS

4,

5

Show

branch

of service,

duty status

on date

of death

(if

known),

and

date

of discharge

or separation

(if known) of

AND 6.

deceased.

ITEMS

7,

8,

Show

your

full name

relationship

to

deceased,

your

date

of birth

and

Social

Security

number.

9 AND

10.

If you were married to the deceased

when

he/she

died,

but

were not

named

as

his/her

insurance

beneficiary,

complete Item

11A through

14C as applicable.

If you were not married to the deceased when he/she died and were not specifically named as his/her insurance beneficiary, complete Part II through 15D. Be sure to provide the required information as to the deceased’s marital status and any children. In Items 15A through 15D give the information about persons indicated in the answers to the preceeding questions. In Part II use a separate signed sheet if necessary.

Complete Part Ill if you were not named as the insurance beneficiary, were not married to the deceased at his/her death and are not a parent of the deceased.

Part IV must be completed by all claimants

EVIDENCE REQUIRED

If the deceased died while on active duty or while a member of a Reserve or National Guard Unit, the Office of Servicemen’s Group Life Insurance will be furnished with proof of death by the Uniformed Service. In all other situations, the claimant must submit a certified copy of the Certificate of Death.

Members performing duty on a full-time basis usually over 30 days and qualified members of the Ready Reserve are insured for 120 days following separation. Members totally disabled at separation may be insured for up to one year following separation as long as total disability continues. If the insured died while covered following separation from service, the claimant must also submit a copy of a report of separation, DD 214.

You will be informed if it becomes necessary to submit other evidence.

If you need assistance in completing this claim form, contact your nearest Department of Veterans Affairs Office.

*lJS Government PrlntlngOftce 1991 282-804127202