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GROUP LIFE INSURANCE CLAIM FORM GROUP POLICYHOLDER S STATEMENT Group Policyholder s name Name of insured employee/member We certify that the above employee/member last worked as of Name of Deceased Amount of Insurance being claimed Name of beneficiary Dated at Certificate No. full-time part-time on or was retired disabled Relationship to insured if Dependant this day of by CLAIMANT S STATEMENT. Authorized Official Signature Claimant s name in full Your SIN No. Your date of birth Deceased s birth date Deceased s address I hereby certify that I am the beneficiary last appointed under Group Policy No. I hereby authorize any physician medical practitioner hospital clinic or other medical or medically related facility insurance company or other organization institution or person that has any records or knowledge of the health of name of deceased to give to The Empire Life Insurance Company or its reinsurers any and all information with reference to the health and medical history of the dece....

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Empire Life has a great mobile app that allows members to easily and seamlessly navigate between features such as: Have access to their Empire Life group benefits policy on the go.

Routine claims are handled within 5 business days. If we require additional information, we will contact you.

How do I cancel or surrender my life insurance policy? You can also contact us directly by emailing insurance@empire.ca or calling 1 800 561-1268.

If you have any questions about your EOBs, call The Empire Plan at 1-877-7-NYSHIP (1-877-769-7447) and select the appropriate program.

Call 1 800 561-1268 or 1 613 548-1881 to start the claim process.

and Empire BlueCross HMO is the trade name of Empire HealthChoice HMO, Inc. independent licensees of the Blue Cross Blue Shield Association, serving residents and businesses in the 28 eastern and southeastern counties of New York State.

Empire Life is a subsidiary of E-L Financial Corporation Limited. Since 1956, three generations of the Jackman family have been involved with Empire Life and have controlled E-L Financial since its incorporation in 1969.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232