Investigation Request

Account Name: *

Account Number:

Requester: *

Contact Phone: *

Contact FAX:

Contact Email: *

Confirm Email: *

Today's Date: *

Type in date xx/xx/xxxx

File Number: *

Date of Loss: *

Type in date xx/xx/xxxx

Date of Issue: *

Type in date xx/xx/xxxx

Type of Investigation: *

Claimant/Subject Name: *

Address:

City

State/Province

Zip/Postal

Country

Date of Birth: *

Type in date xx/xx/xxxx

SSN: *

DL#:

Employer:

Occupation:

Employer Address:

City

State/Province

Zip/Postal

Country

Employer Phone:

Nature of Loss:

Amount of Loss:

Smoking: (Y/N)

Yes

No

Location of Loss:

Beneficiary/NOK: *

Beneficiary Address:

City

State/Province

Zip/Postal

Country

Beneficiary Phone: *

Attorney:

Attorney Phone:

Known Medical Provider 1 - Name:

Known Medical Provider 1 - Phone

Known Medical Provider 1 - Address:

Known Medical Provider 2 - Name:

Known Medical Provider 2 - Phone

Known Medical Provider 2 - Address:

Known Medical Provider 3 - Name:

Known Medical Provider 3 - Phone

Known Medical Provider 3 - Address:

Special Instructions: (up to 1000 characters allowed)

Foreign Death Claim Checklist

If necessary, you may download a Foreign Death Claim Checklist by clicking HERE. After completing the form, please attach it below.

At least one attachment is required before clicking "Submit".

File 1: *