PROOF OF DEATH FORM
This Policy is for an additional $10,000.00 of Life Insurance at no charge at all paying members.
(Except for Retiree’s) The Certification of Eligibility is to be completed by the administrator or trustee of the________________________________________________________Welfare/Pension Fund.
CERTIFICATE OF EIIGIBILTY
This is to certify that____________________________________, deceased, at the time of his application and at date of death was: ______________________________________ A member in good standings of the
LABORERS’ LOCAL 566 WELFARE/PENSION FUND.
_______$10,000.00_______
Amount of Insurance
___________________________________________________ Administrator or Trustee
Address: Welfare/Pension Fund
Phone#
Date
INSTRUCTIONS FOR COMPLETING PROOF OF DEATH:
The beneficiary must complete the following statement and attach a certified copy of the certified copy of the certificate of death. In any case where a claim for accidental death is being made, consideration of such can be facilitated by furnishing a newspaper account, police report, or the coroner’s verdict in addition to the proof of death. If the policy is payable to the estate or executors or administrators of the Insured, the Statement of Beneficiary must be completed by the executor or administrator, a certificate of whose appointment and qualification must be attached. If the policy is payable to a minor, the statement of Beneficiary must be completed by the guardian and an official certificate of the guardians appointment and qualification must be attached.
STATEMENT OF BENEFICIARY
Name & Address of Deceased: Date of Death: Cause of Death (If accident-describe)
Date of Death:
Source from which DOB Obtained:
______Birth Certificate _____Other
Name & Address of Employer:
Date Last Reported for Work:
Duration of Employment:
Occupation at Death:
From:____________________________ To: ______________________________
Name & Address of Beneficiary:
Relationship:
DOB: _______________
------------------------------------------------------------------------------------------------SSN: _________________________________________________________________
To all Physicians, hospitals, clinics, druggists, insurance companies or other organizations, institutions, or persons, you are hereby authorized to disclose to the above named Welfare/Pension Fund any and all information with respect to illness, injury, medical history, consultation, prescriptions, or treatments and copies of all hospitals or medical records of:
_______________________________________________, my______________________________who died___________________ (Name of Deceased) (Relationship) Today’s Date: _______________________________ Signature of Beneficiary:_________________________________________