CLAIM
FOR DEATH BENEFITS
(NSLI) by K Policy
(Servicemen’s Group Life Insurance) (Servicemembers' Group Life Insurance) (Veterans’ Group Life Insurance)
\lOTE. THIS FORM IS NOT TO BE USED FOR NATIONAL SERVICE LIFE INSURANCE JNITED STATES GOVERNMENT LIFE INSURANCE (USGLI) Policy Numbers Prefixed NAME OF DECEASED (FKS,, mrddle. /ast,
RETURN COMPLETED FORM TO: OFFICE OF SERVICEMEMBERS' GROUP LIFE INSURANCE INSURANCE OFFICE OF SERVICEMEN’SE 80 Livingston Avenue Roseland, NJ 07068-1733 Newark, New Jersey 07102-2999 Numbers Prefixed by V, H, RH, RS, W, J, JR and JS or
2 SOCIAL SECURITY NUMBER
3. DATE OF DEATH
‘LEASE
READ
THE IMPORTANT
INFORMATION
AND
INSTRUCTIONS PART I-
ON REVERSE INFORMATION
BEFORE
COMPLETING CLAIMANT
CONCERNING
VOTE -
Comolete
Items
11A throuah
14C if vou are the widow
or widower
of deceased.
attach
copy
Of Ihe
d,“orce
decree,
0
YES
ON0
(,‘
“Yes.
” complete
148
and
14c,
cl
DEATH
cl
DIVORCE
VOTE -
If vou are not the named
beneficiarv.
widow
PART II -
or widower
INFORMATION
of the deceased,
CONCERNING
comolete
NEXT-OF-KIN
Parts
II and III.
OF DECEASED
-1st below a) Wrdow If none, b) If there IS and c) If there Is father d) If there
the name, or Widower, was Insured
age,
relationship, cl ever None married?
and
address
of:
(Check
appropriate
p/aces below)
cl 0 Death Divorce child Give Give or illegitimate Date Date child stating whrch class it
0
Yes
0
No
If yes, did
marriage
terminate Include here cl
by any adopted
is no survivrng list the descendants are no children deceased? are no survivors 0
wrdow
or widower, of any deceased
list all the children child or children.
of the deceased. If none, check parent deceased?
or descendants Yes within
NAME
of chrldren, 0 No Indicated
lrst the survivrng Is mother in (a) through
AGE 1
or parents. 0 Yes 0 No may
1
the degrees
(c). list below
15C. RELATIONSHIP
the next
of km who
be capable
of inheriting
from
the deceased
(brothers,
sisfers,
descendants
of deceased
15A
brothers,
sisters, etc.).
1 158. TO DECEASED 15D. ADDRESS
VOTE - Complete Items 16 and 77 ONLY if any of the persons listed above 5 NAME AND ADDRESS OF GUARDIAN FOR ANY MINOR CHILDREN LISTED ABOVE IF ONE HAS COURT (Attach copy or appOmme”f paper issued by court,
are under age 21. BEEN APPOINTED BY THE
PART 3
NAME AND ADDRESS
Ill IF
INFORMATION
ANY. APPOINTED
CONCERNING BY THE COURT TO
THE
SETTLE
ESTATE THE
OF THE DECEASED
ESTATE
THEDECEASED
OF EXECUTOR
OR
ADMINISTRATOR,
OF
19 IF
AN EXECUTOR APPOINTED. WILL
OR
ONE
ADMINISTRATOR BE APPOINTED?
HAS
NOT
BEEN
0 YES q N0
PART HEREBY CERTIFY that all statements )f this clarm is suppressed or wrthheld. IV CERTIFICATION BY CLAIMANT to a settlement In: made In thus claim are true to the best of my knowledge, informatron, and belief, and that no evidence necessary In the event the Insured has not previously elected monthly Installments. I request that the death benefit be paid III 36 Eaual Monthlv Installments.
Check one)
El
One
Sum
WARNING mprisonment
Any rntentronal false statement in thus claim or willful of not more than 5 years, or both. (16 U.S.C. 1001).
JULY 19%
SEPTEMBER 2007
misrepresentation
relative
thereto
is subject
to punrshment
by a fine of not more
than
$10,000
or
SGLV-8283
EXISTING
STOCKS
OF SGLV 8283,
JAN 1991, WILL BE USED.
IF ADDITIONAL
SPACE
IS REQUIRED,
ATTACH
SEPARATE
SIGNED
SHEETS.
INSTRUCTIONS
TO CLAIMANTS
THIS FORM SHOULD BE USED WHEN THE DECEASED HAD INSURANCE IN FORCE UNDER SERVICEMEN’S GROUP LIFE INSURANCE INSURANCE THIS FORM SHOULD BE USED WHEN THE DECEASED HAD INSURANCE IN FORCE UNDER SERVICEMEMBERS' GROUP LIFE (SGLI) OR VETERANS’ GROUP LIFE INSURANCE (VGLI). (SGLI) OR VETERANS' GROUP LIFE INSURANCE (VGLI).
PAYMENT
OF DEATH
BENEFITS Group Life Insurance death benefit payments must be made in the following to order:
Under Servicemen’s Under Servicemembers'and Veteran’s and
l
To the beneficiary the widow
named
in writing
by the insured;
if none, the insurance to
is payable
l
or widower
of the insured;
if none, it is payable
l
child or children payable to parent(s)
in equal shares with the share of any deceased to
child distributed
among
the descendants
of that child; if none, it is
l
in equal shares; if none, it is payable executor or administrator
l
a duly appointed other next of kin.
of the insured’s
estate, and if none, to
l
COMPLETION
OF CLAIM
FOR DEATH
BENEFITS or incomplete servicewoman If the deceased answers will delay settlement of the claim. All
It is important that all requested information be furnished. Omission information should be typed or printed in ink, except the signature. ITEM 1. ITEM 2. ITEM 3. ITEMS 4, 5 AND 6. ITEMS 7, 8, 9 AND 10. If you were married 14C as applicable. Show full name of the deceased Show Social Security number. number serviceman, of deceased.
or veteran. did not have a Social Security number show service
Show date of death of deceased. Show branch deceased. of service, duty status on date of death (if known), to deceased, and date of discharge or separation number. complete Item 11A through (if known) of
Show your full name relationship to the deceased when
your date of birth and Social Security as his/her insurance beneficiary,
he/she died, but were not named
If you were not married to the deceased when he/she died and were not specifically named as his/her insurance beneficiary, complete Part II through 15D. Be sure to provide the required information as to the deceased’s marital status and any children. In Items 15A through 15D give the information about persons indicated in the answers to the preceeding questions. In Part II use a separate signed sheet if necessary. Complete Part Ill if you were not named parent of the deceased. Part IV must be completed EVIDENCE REQUIRED as the insurance beneficiary, were not married to the deceased at his/her death and are not a
by all claimants
If the deceased died while on active duty or while a member of a Reserve or National Guard Unit, the Office of Servicemen’s Group Life Office must submit a certified copy Insurance will be furnished with proof of death by the Uniformed Service. In all other situations, the claimant of Servicemembers' Group Life of the Certificate of Death. Members performing duty on a full-time basis usually over 30 days and qualified members of the Ready Reserve are insured for 120 days following separation. Members totally disabled at separation may be insured for up to one year following separation as long as total disability continues. If the insured died while covered following separation from service, the claimant must also submit a copy of a report of separation, DD 214. You will be informed If you need assistance if it becomes in completing necessary to submit other evidence. your nearest Department of Veterans Affairs Office.
this claim form, contact
*lJ S
Government
PrlntlngOftce
1991
282-804127202