ASSIGNMENT FORM

Please complete as much information as possible to initiate your claim verification. Download the necessary forms below and print. Complete the forms, then upload or attach the forms, as well as any images of the insurance policy(ies), certificate of death, and beneficiary ID(s). This will expedite your claim.

Irrevocable Assignment

Affidavit of Lost Policy

Affidavit of No Estate

Same Name Affidavit

Download all forms

Assignment Form

Director/Contact Person:*
Insured Name:*
First Name, Middle Name or Initial Last Name
Date of Birth:
Date Format: MM slash DD slash YYYY
Date of Death:
Date Format: MM slash DD slash YYYY
Cause of Death:
- Natural
- Homicide
- Accident
Social Security Number:
#1 Insurance Company:
#1 Insurance Policy Number:
#1 Insurance Policy Beneficiary(ies):
#2 Insurance Company:
#2 Insurance Policy Number:
#2 Insurance Policy Beneficiary(ies):
Attach images of beneficiary(ies) driver's licenses, any signed form(s), front page & beneficiary page of the insurance policy and beneficiary ID(s), if available. This will expedite your claim.
Drop files here or
Additional Details (if any):
Obit Code
(if unknown leave blank)
Captcha

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Assignment Form