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Get Aetna Affidavit Of Sole Survivors

Mail to SRC an Aetna Company Aetna Affidavit of Sole Survivors Attn Claim Department PO Box 14079 Lexington KY 40512-4079 Fax to 1-859-455-8650 Phone 1-888-772-9682 Instructions This form is for informational purposes only and completion does not constitute a claim for any type of benefits. Please provide information only for those next of kin who survive and those who died AFTER the death of the insured. Please use the reverse side of this form for additional children/siblings and indicate the relationship Print or Type Information Decease s Social Security Number Name of Deceased Next of Kin Husband or Wife All Children Natural or legally adopted. No Step-children Print First Name and Last Name Date of Birth Death Date of Death Social Security Number Policy Number Street Address City State Zip Code Parents Natural Father or Adoptive parents Mother All Brothers Sisters legally adopted. No Step-siblings If none of the above survive provide insured s estate representative information Name of Estate Representative Address street city state zip code Telephone Number Informant Information Please Print Informant Name Informant Address Informant Telephone Number SEAL REQUIRED I affirm under penalty of false statement that the information provided is true and complete to the best of knowledge and belief. Informant Signature Subscribed and sworn to before me this day of Notary Public Signature Commission Expires GC-1569-1 4-09 in the State of. Mail to SRC an Aetna Company Aetna Affidavit of Sole Survivors Attn Claim Department PO Box 14079 Lexington KY 40512-4079 Fax to 1-859-455-8650 Phone 1-888-772-9682 Instructions This form is for informational purposes only and completion does not constitute a claim for any type of benefits. Please provide information only for those next of kin who survive and those who died AFTER the death of the insured* Please use the reverse side of this form for additional children/siblings and indicate the relationship Print or Type Information Decease s Social Security Number Name of Deceased Next of Kin Husband or Wife All Children Natural or legally adopted* No Step-children Print First Name and Last Name Date of Birth Death Date of Death Social Security Number Policy Number Street Address City State Zip Code Parents Natural Father or Adoptive parents Mother All Brothers Sisters legally adopted* No Step-siblings If none of the above survive provide insured s estate representative information Name of Estate Representative Address street city state zip code Telephone Number Informant Information Please Print Informant Name Informant Address Informant Telephone Number SEAL REQUIRED I affirm under penalty of false statement that the information provided is true and complete to the best of knowledge and belief* Informant Signature Subscribed and sworn to before me this day of Notary Public Signature Commission Expires GC-1569-1 4-09 in the State of.

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