Rev. 3.5.19
On behalf of HealthChoice, please accept our sincere condolences during this difficult time.
This packet contains the forms and lists the steps you need to follow in order to submit your life insurance claim.
Forms enclosed:
Life Insurance Claim Form.
Electronic Funds Transfer Authorization Form.
Funeral Home Designation Form.
Steps to submit your claim:
1. Decide – You have the following options to receive your life insurance proceeds:
• Electronic funds transfer to your personal banking account.• A check that we mail to you.
2. Complete – Fill out the enclosed Life Insurance Claim Form. Please provide all information requested so we may process your claim as quickly as possible. Missing or incorrect information could delay your claim.
3. Return – Please mail your completed claim form and additional documents to:
HealthChoice Life Claim Department
P.O. Box 2338
Little Rock, AR 72203
What to expect after you submit your claim:
We are committed to processing your claim as quickly as possible. Once we receive all your information and
verify benefits, we typically can process a claim within 10 business days. If we approve your claim we will
process your payment according to your request (i.e. mailed check or EFT).
We recognize this may be a challenging time for you. If you have questions or need assistance completing your
claim form, please call customer care toll-free at 800-323-4314, Monday through Friday, 7:30 a.m. to 5:00 p.m.
Central time.
Sincerely,
HealthChoice Life Team
Rev. 3.5.19
Please Print
LIFE INSURANCE CLAIM FORM Use this form to submit your claim for a life insurance payment. Each potential beneficiary submitting a claim must complete and submit a separate claim form. For questions, please call toll free at 800-323-4314.
Section 1: Information about the deceased First name
Middle initial Last name
Social security number
Date of birth (mm/dd/yyyy) Date of death (mm/dd/yyyy)
Section 2: Information about the claimant
First name
Middle initial Last name
Mailing address (Street number/name, apartment or suite)
City/State/Zip
Phone number Date of birth (mm/dd/yyyy)
Section 3: Claim Payment Election (check one)
I would like to receive my payment through Electronic Funds Transfer. (safer, more secure, and
efficient)
I would like to receive my payment via mailed check.
Section 4: Additional Documentation Checklist
Death certificate. A certified death certificate or certified copy is required. Only one certified death
certificate is needed; if you’re aware of another claimant who’s sending one, do not send another
copy.
Electronic Funds Transfer Form. If you would like your payment sent directly to your bank account
electronically, please complete and return the enclosed form.
Funeral Home Designation Form. If you would like to authorize payments directly to the funeral home,
please complete and return the enclosed form.
Proof of accident. If the deceased died in an accident, and you are making an accidental death benefit
claim, please provide proof of the accident – police reports or other supporting documents.
Power of attorney. If you have a Power of attorney, please provide a copy of the appointment papers
naming you as the attorney-in-fact for the beneficiary.
By signing below, I certify that all information provided above is true and complete to the best of my
knowledge.
Claimant signature: ___________________________________ Date: _________________________
Rev. 3.5.19
Please Print
ELECTRONIC FUNDS TRANSFER AUTHORIZATION FORM Use this form to authorize approved life insurance payments to be submitted to your financial institution through an electronic funds transfer. For questions, please call 1-800-323-4314.
Section 1: Information about the claimant
First name
Middle initial Last name
Mailing address (Street number/name, apartment or suite)
City/State/Zip
Phone number Date of birth (mm/dd/yyyy)
Section 2: Banking information
Checking Savings
Please attach a voided check.
Routing number
Account number
By signing below, I certify that all information provided above is true and complete to the best of my
knowledge.
Claimant signature: ___________________________________ Date: _________________________
Rev. 3.5.19
Please Print
FUNERAL HOME DESIGNATION FORM Use this form to designate all or a portion of your life insurance payments, once approved, to a designated funeral home. For questions, please call 1-800-323-4314. Our Customer Service team is open Monday through Friday, 7:30 a.m. to 5:00 p.m. CST.
Section 1: Information about the deceased First name
Middle initial Last name
Social security number
Date of birth (mm/dd/yyyy) Date of death (mm/dd/yyyy)
Section 2: Information about the claimant
First name
Middle initial Last name
Phone number Date of birth (mm/dd/yyyy)
Section 3: Information about the funeral home
Name of funeral home
Contact/Representative name
Address (Street number/name, apartment or suite)
City/State/Zip
Phone number Tax identification number
Banking institution name
Bank City/State
Bank phone number
Routing number
Account number
Authorized amount for payment to funeral home: $__________________
Claimant signature _____________________________________ Date: __________________________
Witness signature: _____________________________________ Date: ___________________________
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