Start Your Claim

We understand the loss of a loved one is very stressful, and we’re here to help in any way we can. During this process, please feel free to reach out at any time.

Please fill out and submit the required information through the form below. It is also helpful if you fill out the non-required information as best you can. Using this electronic form enables us to pre-fill much of the claim packet for easier completion. Submitting this form officially notifies us and starts the claim process. We will contact you or the beneficiary listed to follow up and advise you of the next steps in the process.

* INDICATES REQUIRED FIELD -- Please correct the errors noted below to complete submission.

Tell Us About Yourself

Prefix

First Name *

Middle Initial

Last Name *

Suffix

Phone Number *

Email Address *

Role *

Tell Us About the Deceased

Prefix

First Name *

Middle Initial

Last Name *

Suffix

Policy/Contract Number or Social Security Required *

Policy/Contract Number

Additional Policy/Contract Number

Social Security Number

Date of Birth *

Date of Death *

Cause of Death*

Manner of Death *

Country of Death *

Do you have any information concerning the beneficiary?

Do you have any information concerning the funeral home/obituary?

Beneficiary Information

Beneficiary Type

Organization Type

Name

Address

Phone Number

Email Address

EIN

SSN

Prefix

First Name

Middle Initial

Last Name

Suffix

Date of Birth

Address

Phone Type

Phone Number

Email Address

Would you like to receive status alerts?

Email Text Message and data rates may apply Terms and Conditions

Please provide your mobile number

Please confirm your mobile number

Role

Social Security Number

Funeral Home/Obituary Information

Funeral Home Name

Funeral Home Website

Funeral Home Address

Funeral Home Email Address

Funeral Home Phone Number

Funeral Home Fax Number

Funeral Home Assignment

Date of Obituary

Newspaper of Obituary