INSTRUCTIONS:

1. The Claimant Statement must be executed by the person(s) to whom the insurance proceeds are payable, if of legal age.  Every question must be fully answered.  If there is more   than one beneficiary, each must execute a separate form.

2. The Authorization on page two (2) of the Claimant Statement must be completed by the next of kin or personal representative of the deceased.

3. When insurance proceeds are payable to an estate, the Claimant’s Statement must be executed by the Administrator or Executor and a certified copy of Letters of Administration or Letters Testamentary must be furnished.

4. When insurance proceeds are payable to a minor, the Claimant’s Statement must be executed by a guardian and a certified copy of Letters of Guardianship must be furnished.

5. If any part of the proceeds of a policy is payable to “children” or to others of a designated class, an affidavit must be furnished giving the name and date of birth of each and stating that the persons named in the affidavit constitute all of the class designated in the policy.  If any have died, the affidavit must give the date and place of death.

6. The Physician Statement must be executed by the policyholder's physician at the time of death.