Follow the steps to complete the form efficiently.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with Part I, the Employer’s Statement, which must be filled out completely. Ensure that it is signed by the official representative of the employer. Attach a certified copy of the Death Certificate stating the cause and manner of death.
3. Provide proof of salary as specified in the policy, such as W-2 forms or commission records. If claiming any voluntary or contributory life plans, include enrollment forms that demonstrate timely enrollment.
4. Submit any necessary beneficiary designation forms on file with the employer. If none exist, the employer must certify this fact on the claim form.
5. Proceed to Part II, the Beneficiary Statement. If there are multiple beneficiaries, each can either sign one form or complete separate ones, including their current address, date of birth, and social security number.
6. If the claim is for accidental death, provide any police reports, autopsy, or other pertinent information if available.
7. Complete any miscellaneous requirements. If the claim proceeds go to an estate, Part II must be filled out by the executor or administrator, along with an official certificate of their appointment.
8. Ensure that all supporting documentation, such as a student enrollment verification form if claiming for a dependent child, is included.
9. Save your changes, and opt to download, print, or share the form as necessary for submission.

Take action now and complete your documents online for an efficient filing experience.