Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by filling in the group policyholder’s statement. Provide the group policyholder’s name, the name of the insured employee or member, and the last working date of the insured individual.
3. Input the name of the deceased along with the claimed amount of insurance in the respective fields. Don't forget to include the name of the beneficiary and the group policy and certificate numbers.
4. Indicate the employment status of the insured by checking the appropriate box for full-time, part-time, retired, or disabled.
5. In the claimant's statement, fill in the claimant's name, social insurance number, relationship to the deceased, date of birth, and the deceased's birth date and address.
6. Certify that you are the appointed beneficiary and authorize access to medical records of the deceased. Fill in the date of death and the cause of death.
7. If applicable, fill out the doctor’s statement section if the claim amount is $75,000 or more. Provide the required information about the deceased and the cause of death.
8. After completing all sections, review the information for accuracy and completeness.
9. Finally, you can save the changes, download the completed form, and print or share it as needed.

Ensure you follow these steps to complete your documents accurately online.