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Get VRS-5562;J256012 R EL VRS-5562 3-2014 - LifeBenefits.com 2014-2024

(last, first, middle initial) m For claim information call: 1-800-441-2258 Social Security number CLAIM NUMBER Address (street, city, state, zip) Name of deceased (if different than above) (last, first, middle initial) Date of birth (mo/day/yr) Social Security number Address (street, city, state, zip) Name of beneficiary (last, first, middle initial) Relationship to deceased Date of birth of beneficiary CERTIFICATION INSTRUCTIONS: You must cross out item (2) below if you have been notif.

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