Claim

Claim Form



Membership information:

Certificate Number
Date of Issuance
The original of membership certificate is attached (Required)

Deceased member information:

Date of birth
Date of death
An original certified death certificate showing cause and manner of deathis attached.(Required)
Has the deceased been diagnosed with a chronic disease in the past 5 years?
Yes No
Has the deceased been diagnosed with a terminal illness?
Yes No

Claimant Information

In what capacity are you claiming the death benefit?
Spouse of decedent
Beneficiary (individual)
Executor, administrator, or personal representative - Include court certificate of appointment
On behalf of minor child, as attorney-in-fact or as custodian or guardian - Include appropriate documentation
Foreign Beneficiary – Must include all the appropriate IRS forms. Contact your CPA if possible
Other -(If former spouse, include copy of the divorce decree and settlement agreement.)

Claimant Contact Information

Date of birth
Social Security

Settlement Options(elect only one option)

Lump sum settlement
Payment of the balance after settlement of the following items:
  • Administrative procedure and paperwork
  • Negotiations with the mortuary and funeral home
  • In case of burial here in USA, we negotiate the acquisition of a piece of land
  • In case of repatriation of corpse, we process the Air freight modalities

Note: need more assistance after burial here in USA, or upon arrival in case of repatriation, please contact us for further arrangements. Together, we challenge your stress

 


 

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