"Death Claim Reporting Form - Gulf Guaranty Life Insurance Company"

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GULF GUARANTY LIFE INSURANCE COMPANY
P.O. BOX 12409
JACKSON, MS 39236-2409
800-248-3146
DEATH CLAIM REPORTING FORM
NAME OF INSURED ________________________________________________________________
CERTIFICATE OR REFERENCE NO. __________________________________________________
ORIGINAL AMOUNT OF INSURANCE ________________________________________________
DATE OF CERTIFICATE __________________________ TERM OF CERTIFICATE ___________
AMOUNT PAID ON LOAN PRIOR TO DATE OF DEATH _________________________________
MONTHS PAST DUE ON DATE OF DEATH _____________ EXTENTIONS ________________
NET PAYOFF DUE CREDITOR ON DATE OF DEATH ___________________________________
NAME OF SECOND BENEFICIARY ___________________________________________________
NAME OF CREDITOR _______________________________________________________________
CONTACT _________________________________________________________________________
EMAIL ADDRESS ___________________________________________________________________
MAILING ADDRESS ________________________________________________________________
CITY, STATE, ZIP ___________________________________________________________________
PHONE NO. (
)____________________
THE FOLLOWING DOCUMENTS MUST BE ATTACHED TO PROCESS CLAIM:
1.
DEATH CERTIFICATE
2.
COPY OF NOTE AND DISCLOSURE STATEMENT
3.
COPY OF PAYMENT HISTORY
4.
PRINTOUT SHOWING HOW NET PAYOFF WAS CALCULATED –
BE SURE PER DIEM IS SHOWN ON PRINTOUT
Rev. 9-21-15
GULF GUARANTY LIFE INSURANCE COMPANY
P.O. BOX 12409
JACKSON, MS 39236-2409
800-248-3146
DEATH CLAIM REPORTING FORM
NAME OF INSURED ________________________________________________________________
CERTIFICATE OR REFERENCE NO. __________________________________________________
ORIGINAL AMOUNT OF INSURANCE ________________________________________________
DATE OF CERTIFICATE __________________________ TERM OF CERTIFICATE ___________
AMOUNT PAID ON LOAN PRIOR TO DATE OF DEATH _________________________________
MONTHS PAST DUE ON DATE OF DEATH _____________ EXTENTIONS ________________
NET PAYOFF DUE CREDITOR ON DATE OF DEATH ___________________________________
NAME OF SECOND BENEFICIARY ___________________________________________________
NAME OF CREDITOR _______________________________________________________________
CONTACT _________________________________________________________________________
EMAIL ADDRESS ___________________________________________________________________
MAILING ADDRESS ________________________________________________________________
CITY, STATE, ZIP ___________________________________________________________________
PHONE NO. (
)____________________
THE FOLLOWING DOCUMENTS MUST BE ATTACHED TO PROCESS CLAIM:
1.
DEATH CERTIFICATE
2.
COPY OF NOTE AND DISCLOSURE STATEMENT
3.
COPY OF PAYMENT HISTORY
4.
PRINTOUT SHOWING HOW NET PAYOFF WAS CALCULATED –
BE SURE PER DIEM IS SHOWN ON PRINTOUT
Rev. 9-21-15