Follow the steps to successfully complete your claim form.

1. Click ‘Get Form’ button to access the Combined Insurance Claim Form and open it for editing.
2. Begin by entering the decedent's full name, ensuring accuracy as this will be crucial for the claim process.
3. Input the policy number and form/plan number in the designated fields. These can typically be found on the insurance policy documents.
4. List any other names the deceased may have used, such as a maiden name or alias, in the provided section to avoid any discrepancies.
5. Fill in the decedent's address, including street, city, state, and zip code.
6. Enter the decedent's date of birth and date of death, ensuring the format is correct to prevent errors in processing.
7. If the death was due to sickness, provide details about the nature of the sickness. If the death was accidental, complete the relevant section regarding the nature of injuries and provide a description of where and how the accident occurred.
8. Provide the beneficiary's full name, date of birth, relationship to the deceased, and contact information including mailing address, home telephone number, email address, and cell telephone number.
9. If the beneficiary is a minor, include the name and address of the parent or guardian.
10. Review the fraud notification section, confirming that you understand the implications of providing false information.
11. Sign and date the form, certifying the accuracy of the information provided. If necessary, include your printed name and Social Security or Tax ID number.
12. Attach any required documentation, such as a certified copy of the death certificate and an obituary notice, if available.
13. Finally, save your changes, download the completed form, and print or share it as needed to submit your claim.

Start filling out your Combined Insurance Claim Form online today to ensure a smooth claims process.