Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online document editor.
2. Begin with Section I, which requires the insured's information. Fill in fields such as the insured's name, social security number, policy number(s), claim number(s), date of birth, date of death, address, and cause of death.
3. Navigate to Section II to provide the beneficiary information. Enter the beneficiary's name, relationship to the insured, social security number, date of birth, mailing address, daytime phone number, and email address.
4. For Section III, complete the details if the beneficiary is a trust or estate. Include the Trust or Estate name, tax identification number, and the mailing address along with contact information for the trustee or estate personal representative.
5. In Section IV, select your settlement or distribution option. Specify if you prefer a lump sum payment or to annuitize benefits. If choosing annuitization, select one of the provided options and enter contingent payee details if necessary.
6. Complete Section V by providing medical information only if the policy was issued or reinstated within two years of the death. List the names and addresses of all doctors who treated the insured along with the dates of treatment and conditions.
7. Sign and date Section VI which is the authorization section for medical records relevant to the claim. Ensure the relationships and permissions are accurately documented.
8. In Section VII, certify the taxpayer identification number(s) under penalty of perjury. This section includes relevant statements regarding backup withholding and tax requirements.
9. Finally, in Section VIII, provide your signature and date the form. If the original policy is lost, indicate this with an 'X' in the appropriate box and provide a statement certifying the loss.
10. Once completed, ensure you have reviewed all sections for accuracy. You can then save, download, print, or share the filled form as needed.

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