To submit this form, complete all required sections and attach supporting documents including the certified death certificate. Mail the completed form to AIG Benefit Solutions at 3600 Rt. 66, Neptune, NJ 07753. Alternatively, you can call 800-250-8898 for further instructions or assistance with submission. Ensure all information is accurate to avoid delays.

There are no specific important dates for this form in 2024 and 2025. Dates depend on the individual case and claim submission timeline.

The purpose of this form is to facilitate the filing of a death claim with AIG Benefit Solutions. It ensures that all necessary details and documentation are submitted for the prompt processing of claims. By completing the form accurately, beneficiaries and policyholders can expedite the claim evaluation and receive benefits without unnecessary delays. The form primarily gathers information about the deceased, the policyholder, and the beneficiaries, along with supporting documents such as the death certificate and proof of enrollment. It includes sections that must be completed by authorized representatives of the policyholder, designated beneficiaries, and in some cases, the attending physician. The detailed instructions provided in the form help prevent errors and ensure that all necessary information is gathered.

• 1. Statement of Policyholder: To be completed by an authorized representative of the policyholder with details and signature.
• 2. Claimant's Section: To be completed and signed by the designated beneficiary, including personal details and relationship to deceased.
• 3. Attending Physician's Statement: To be completed by the physician if the deceased was disabled more than 31 days prior to death, detailing cause and duration of disability.
• 4. Certified Copy of Death Certificate: A copy of the official death certificate must be attached to the form.
• 5. Proof of Enrollment: Documentation to confirm the deceased’s enrollment in the insurance policy.
• 6. Beneficiary Designation Form: Form indicating the designated beneficiary for the policy benefits.

Failure to submit this form may result in delays or denial of death claim benefits. Submitting all required information promptly is crucial.

• Delay in Payment: Benefit payments may be delayed if the necessary documentation is not submitted on time.
• Denial of Claim: Incomplete or incorrect submissions may result in the denial of the death claim.
• Lack of Benefits: Beneficiaries may not receive the entitled benefits if the form is not properly completed and submitted.

• 1. After Policyholder's Death: Submit this form to claim death benefits for the deceased policyholder.
• 2. For Beneficiary Claims: Beneficiaries should use this form to provide necessary details for processing the claim.
• 3. In Case of Minor Beneficiary: Guardians should complete the form and submit certified guardianship papers if the beneficiary is a minor.
• 4. Submission of Death Certificate: Attach the certified copy of the death certificate with the form for validation.
• 5. Policyholder Representation: Authorized representatives must complete and sign the relevant sections.