Follow the steps to successfully complete your claim form.

1. Press the ‘Get Form’ button to access the Empire Life Insurance Claim Form. This will allow you to open the document in your preferred online editor.
2. Fill in all required fields at the top of the form, including the group number, division number, and certificate number. These identifiers ensure that your claim is processed correctly.
3. Provide the insured's name, date of birth, and address, including all necessary details such as apartment number and postal code. Accurate information is crucial for processing.
4. Specify the phone number and email address for communication about your claim. This ensures Empire Life can reach you if needed.
5. Indicate whether your employment has terminated and, if so, provide the termination date. This helps in verifying your eligibility for the claim.
6. Answer if the claim is related to Worker’s Compensation Benefits. If applicable, describe the nature of the accident and include the accident date and time.
7. If you or any dependents have other Extended Health Insurance coverage, provide the name of the policyholder and relevant policy numbers here.
8. Complete the claim summary section by entering details for each service or purchase, ensuring that you note balances paid through other insurance.
9. Certify the information provided is true and complete by signing the form, and include the date of your signature.
10. Ensure you attach original bills, receipts, and any additional documents such as the Explanation of Benefits from other insurance, if applicable.
11. Once completed, review the form for any missing information. After verification, you can save changes, download, print, or share the form as needed.

Complete your Empire Life Insurance Claim Form online today for prompt processing of your claim.