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  Accidental Death
Information Required: Proof of Death Form
This form is to be used in the event of an accident resulting in the death of an Insured Person. Please refer to the instructions below in completing the three sections of the form:
Employers Statement
This section of the form must be completed by an authorized representative of your company. They must also provide the documentation listed in the left hand margin of the claim form:
• Photocopy of Enrollment card or other proof of enrollment.
• Verification of premium deduction.
Claimant’s Statement
The person authorized to make a claim, must complete this section, providing details of accident. If the deceased person was a dependent of the employee, then the employee must complete sub-section A, Dependent Claim. Sub-section B is to be completed by the beneficiary. Please attach the documentation listed in the left hand margin:
• Certified Copy of Death Certificate
• Copy of newspaper clipping. Police report or Coroners report if applicable.
• Proof of marital status or dependent eligibility.
Waiver of Privileged Communication
This section allows Sutton Special Risk to gather documentation required to process the claim. This should be completed by the beneficiary or a person authorized to allow access to the necessary documentation.
Claim should be submitted to the address indicated on the top left hand side of the claim form. |
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