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Get UnitedHealthcare Request For Group Life Insurance Benefits 2014

ATH FOR GROUP INSURANCE) INSTRUCTIONS: 1. Claimant, please fill in and sign SECTION 1 below. 2. Please include a Certified Death Certificate. 3. If death was the result of an accident, please attach copies of any police report, as well as copies of any toxicology report and autopsy report. 4. Submit this form, with any attachments, to Employer for completion of SECTION 2. SECTION 1 CLAIMANT’S STATEMENT Deceased’s Name: Deceased’s Address: Name of Insured Employee: Deceased’s S.S. Numb.

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