Make An Insurance Claim
Please use the below forms to file a Death Claim or to request a Cash Surrender of an existing Certificate.
PLEASE NOTE: We require the below forms to be downloaded, completed, signed, notarized if applicable, and returned to us via USPS or your preferred shipping method. If you have any questions, please contact us here.
Statement of claim form (To Make a death claim)
Please complete this form to request the payment of any Death Benefits associated with an existing Certificate.
In addition to this form, we require:
An Original Death Certificate embossed with county seal (Photo copies will not be accepted)
The Original Insurance Certificate (Photo copies will not be accepted)
Should you be unable to locate the Original Insurance Certificate associated with the Claim being made, please download and have notarized the below Affidavit by Beneficiary for Issuance of a Duplicate Certificate form.
Upon physical receipt of the above, the due payment benefits for the associated Certificate will be processed.
Affidavit by Beneficiary for issuance of a duplicate certificate
Should you be unable to locate the Original Insurance Certificate associated with a Death Claim being made, please download, complete this form, and return it to us with the above Statement of Claim form.
Please note that we require this form to be notarized before being returned to us.
request for payment of cash surrender value
Please complete this form to request the payment of the Cash Surrender Value associated with an existing Certificate. Please note, Whole Life Certificates issued prior to 1986, Term Insurance, or New Certificates that have not reached five (5) years of age, do not hold Cash Value.
In addition to this form, we require:
The Original Insurance Certificate (Photo copies will not be accepted)
Should you be unable to locate the Original Insurance Certificate associated with the Claim being made, please download and have notarized the Request for Duplicate Certificate form located here.
Upon physical receipt of the above, the due payment benefits for the associated Certificate will be processed.
Please note that we require this form to be notarized before being returned to us.
request and agreement for annuity cash surrender (To close account)
Please complete this form to request the payment of the current balance associated with an existing Annuity Contract. Please note, surrender charges and taxable amount vary depending on the type of Annuity and amount of interest accrued. Please contact us for more information.
In addition to this form, we require:
The Original Annuity Certificate (Photo copies will not be accepted)
Should you be unable to locate the Original Annuity Certificate associated with the Claim being made, please download and have notarized the Request for Duplicate Certificate form located here.
Upon physical receipt of the above, the due balance for the associated Annuity Account will be processed.