NOTICE OF CLAIM PROOF OF DEPENDENT'S DEATH

							                                                                                                            Genworth Financial           Genworth Life and Health Insurance Company
                                                                                                            Employee Benefits Group      PO Box 810
                                                                                                                                         Greenfield, MA 01302-0810


NOTICE OF CL AIM PROOF OF DEPENDENT ’S DEATH
TO: GROUP LIFE BENEFITS                                                                                                                         MUST BE COMPLETED IN FULL
Employer’s Statement
Group Account Number         Name of Employee (First, Middle, Last)                        Maiden Name                 Other Names by which Employee is known as Date of Birth


Effective Date of Employee’s Insurance                                                                             Amount of Employee’s Insurance
                                                                                                                   $
Effective Date of Dependent’s Insurance     Amount of Dependent’s Insurance - Basic                                Supplemental                       Voluntary
                                            $
Occupation of Employee                                                                                             Basic Annual Earnings              Date of Employment

                                                                                                                   $
Was employee’s premium, including premium for deceased dependent, paid and insurance in force on date of dependent’s death? (If “No” give the date Coverage was terminated)
                                                                                                                                   .
  Yes         No
What was employee’s date of last service? (Month, Day, Year)


It is certified that the statements contained above are true to the best of our knowledge and belief.

Signed by __________________________________________________________________________ ______________________________ ___________________________
                                      Signature of Authorized Personnel                                                       Title                              Date Signed
Name of Employer                                                                                                                                      Telephone Number


Employee’s Statement: To be fully completed by the Employee
Name of Deceased Dependent (First, Middle, Last)        Maiden Name               Other Names by which Deceased was known as Date of Birth            Marital Status
                                                                                                                                                         Single        Married
Relationship to Employee                          Date of Death                                  Place of Death (City, State, Country)


                                                              ,
Was this Dependent residing with you at time of death? (If “No” please give the                 If Dependent was hospital confined prior to death, please give date of last
dependent’s address or explain)                                                                 admission and name of hospital.
              Yes         No
                                                                 ,
Was this Dependent a full-time student at time of death? (If “Yes” give name and address        Was this Dependent hospital confined or totally disabled on the effective date of
of school attended.)                                                                            dependent coverage?
              Yes         No
Were you contributing more than 50% of the dependent child’s support?                           If this claim is for a spouse, please provide us with the date the dependent was
              Yes         No                                                                    last actively at work:


I hereby certify that the answers in this statement are complete and true.

Signed by ____________________________________________________________________________                                        __________________________________________
                                             Signature of Employee                                                                                 Date Signed

Address (No. and Street, City, State and Zip Code) _____________________________________________________________________________________________
Proof of Death
A certified copy of Death Certificate from public records must be furnished as Proof of Death. Photocopies are NOT ACCEPTABLE. If on file at your office,
please provide us with a copy of the employee’s Enrollment Card and copies of any subsequent benefit election forms. If death was the result of an
accident please provide us with copies of any applicable newspaper clippings.

WARNING
STATE LAW IN SOME STATES REQUIRES THE FOLLOWING STATEMENT:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false
information or conceals for the purpose of misleading, information concerning any fact material thereto (in Oregon "may be guilty of insurance fraud") commits a fraudulent
insurance act, which (in Oregon "may be subject to prosecution") is a crime and subjects such person to criminal and civil penalties.
THIS NOTICE DOES NOT APPLY IN VIRGINIA.
IN CALIFORNIA: “Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.”
IN FLORIDA: “Any person who knowingly and with intent to injure, defraud, or deceive any insurer, files a statement of claim or an application containing any false, incomplete or
misleading information is guilty of a felony of the third degree.”
IN LOUISIANA: “Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for
insurance is guilty of a crime and may be subject to fines and confinement in prison.”
IN NEW JERSEY: “Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.”
IN NEW YORK: “Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing
any materially false information or conceals for the purpose of misleading, information containing any fact material thereto, commits a fraudulent insurance act which is a crime and
shall be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each violation.”
IN PUERTO RICO: “Any person who, knowingly and with the intent to defraud, presents false information in an insurance request for, or who presents, helps or has presented a
fraudulent claim for the payment of a loss or other benefit, or present more than one claim for the same damage or loss, will incur a felony, and upon conviction will be penalized for
each violation with a fine no less than five thousand ($5,000) dollars nor more than ten thousand ($10,000) dollars, or imprisonment for a fixed term of three (3) years, or both
penalties. If aggravated circumstances prevail, the fixed established imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail, it may be
reduced to a minimum of two (2) years.”
GNW-GL192 (03/06)