Metropolitan Life Insurance Company
One Madison Avenue, New York, NY 10010-3690
BeneficiaryÕs Life Insurance Claim Statement
In order to process your claim as quickly as possible we need some information about you and about the deceased. Each beneficiary must submit his or her own claim statement.
A. Information about you:
1.Your Name (please print or type) _______________________________________________________________________________
First |
Middle Initial |
Last |
2.Your Social Security No. _________________________
3. |
Your Date of Birth ________________________________ |
Your Sex ☐ Male ☐ Female |
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|
Mo. |
Day |
Year |
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|
|
|
4. |
Your Phone Number (in case we need to contact you) |
Day ( |
)_____________ |
Evening ( |
)_____________ |
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|
|
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Area Code |
Area Code |
5.Your Address ______________________________________________________________________________________________
House NumberStreet NameApt./Box No. (if any)
________________________________________________________________________________________________________
CityStateZip
6. Your relationship to the deceased. You are the ☐ Husband or Wife ☐ Child ☐ Parent ☐ Other __________________________
Explain
B. Information about the deceased:
1.His/Her Name______________________________________________________________________________________________
First |
Middle Initial |
Last |
2.His/Her Residence Address____________________________________________________________________________________
House NumberStreet NameApt./Box No. (if any)
________________________________________________________________________________________________________
|
City |
|
State |
|
Zip |
3. His/Her Marital Status |
☐ Single |
☐ Married |
☐ Widow/Widower |
☐ Separated |
☐ Divorced |
4.His/Her Date of Birth ______________________________
|
Mo. |
Day |
Year |
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|
5. |
His/Her Social Security No. ____ / ___ / ______ |
6. His/Her Employer ________________________________________________ |
7. |
We need an officially certified copy of death certificate. Is a copy attached? |
☐ Yes |
☐ No |
|
If not, please state why_______________________________________________________________________________________ |
The information I have given is, to the best of my knowledge, true and accurate. Under penalties of perjury, I certify that the number shown on this form is my correct taxpayer identification number, and that: (please check one)
⬛The Internal Revenue Service (IRS) has notified me that I am subject to backup withholding as a result of a failure to report all interest or dividends, or
⬛I am not subject (or no longer subject) to backup withholding.
The IRS does not require your consent to any provision of this document other than the certifications to avoid backup withholding.
If the insured was covered under a policy issued in one of the states listed below or if you reside in one of the states listed below, one of the following state warnings may apply to you:
New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
If the insured was covered under a policy issued in any state other than those listed above, or if you reside in any state other than those listed above, then the following warning may apply to you:
Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Please sign below as you would sign on checks. If you are receiving a Total Control Account, this signature will be placed with your Account.
_______________________________________________________ _____________________________________________