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C-5082(8/21)
PROOFS OF DEATH-CLAIMANT'S STATEMENT
INSURING COMPANY (Please check one):
American-Amicable Life Insurance Company of Texas • Email: [email protected]
IA American Life Insurance Company • Email: Claims@IAAmerican-Waco.com
Industrial Alliance Insurance and Financial Services Inc. • Email: Claims@IAPlife-Waco.com
Occidental Life Insurance Company of North Carolina • Email: [email protected]
Pioneer American Insurance Company • Email: [email protected]
Pioneer Security Life Insurance Company • Email: [email protected]
P.O. Box 2549 • Waco, TX 76702-2549 • 800-736-7311
By furnishing forms and investigating the claim, the company does not admit that there is any insurance in force and does not waive any
of its rights or defenses.
1. Policy Numbers:__________________________________________________ Amounts:______________________________________________
2. Deceased's name in full:_________________________________________________________________ Marital Status:_____________________
3. Residence at death: Street:____________________________ City:__________________________State:_______________ Zip:_________
4. Usual Occupation (not just Retired): ____________________________________________________________________________________
5. a. Date of deceased's birth: _________________________________________ b. Place of birth:___________________________________
6. a. Date of death: ___________________________________________________ b. Place of death:____________________________________
c. Cause of death: ____________________________________________________________________________________________________
Note: Complete questions 7 through 11 only if policy has been in force less than 2 years and / or accidental benets are claimed.
7. Datedeceasedrstcomplainedof,orgaveotherindicationsofhis/herlastillness:_____________________________________________
8. Whendiddeceasedrstconsultaphysicianforhis/herlastillness?_______________________________________________________________
9. Onwhatdatediddeceasedlastattendtohis/herusualwork?___________________________________________________________
10. Givenamesandaddressofallphysicianswhoattendeddeceasedduringthelastveyearspriorthereto:
Names Addresses Date of Attendance Disease or Condition
11. Inwhatothercompanies,andforwhatamounts,wasthelifeofthedeceasedinsuredunderaccidentand/orlifepolicies?
___________________________________________________________________________________________________________________
12. I hereby certify that the policy of insurance for the listed policy has been ENCLOSED LOST DESTROYED
(If policy is enclosed we must have original; a photocopy is not acceptable)
13. Taxpayer I.D. Information:
Entertheclaimant'staxpayeridenticationnumber
in the appropriate box. For most individuals
this is your social security number
BENEFICIARY/CLAIMANT'SSS.NO. OR TAX I.D. NO.
CERTIFICATION - Under penalties of perjury I certify that
(1) ThenumbershownonthisformismycorrectTaxpayerIdenticationNumber(orIamwaitingforanumbertobeissuedtome)and
(2) IamnotsubjecttobackupwithholdingeitherbecauseIhavenotbeennotiedbytheInternalRevenueService(IRS)thatIamsubjecttobackupwithholdingas
aresultofafailuretoreportatinterestordividendsortheIRShasnotiedmethatIamnolongersubjecttobackupwithholding.
PLEASE
SIGN
HERE
CLAIMANT'S SIGNATURE DATE
14. Dated at______________________________________________this_______________day of_____________________________, 20______.
City & State
15.
Claimant's Signature
__________________________________________Date of Birth_______________Relationship_____________________
Claimant's Printed Name
___________________________________________________
16. Claimant's Mailing Address______________________________ ______________________________________________________________
Street or P.O. Box
_________________________________________________________________________ Daytime Phone No. ___________________________
City State Zip
17. Witness to Signature______________________________________________________ (Does not need to be notarized)
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C-5082(8/21)
Important Notice
In some states we are required to advise you of the following: Any person who, with intent to defraud or knowing that
he is facilitating a fraud against an insurer, submits an application containing a false or deceptive statement may be
guilty of insurance fraud.
Please review the appropriate fraud warning relevant to the state that you reside in prior to submitting your claim.
Alabama – Any person who knowingly presents a false or fraudulent claim for payment of a loss or benet or who
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution,
nes, or connement in prison, or any combination thereof.
Alaska – Any person who knowingly and with intent to injure, defraud, or deceive an insurance company les a claim
containing false, incomplete, or misleading information may be prosecuted under state law.
Arizona – “For your protection Arizona law requires the following statement to appear on this form. Any
person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and
civil penalties.”
Arkansas – Any person who knowingly presents a false or fraudulent claim for payment of a loss or benet or
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to nes
and connement in prison.
California – For your protection, California law requires the following to appear on this form: Any person who
knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to
nes and connement in state prison.
Colorado – It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance
company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment,
nes, denial of insurance and civil damages. Any insurance company or agent of an insurance company who know-
ingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of
defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from
insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
Delaware: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, les a statement of
claim containing any false, incomplete, or misleading information is guilty of a felony.
District of Columbia – Warning: It is a crime to provide false or misleading information to an insurer for the purpose
of defrauding the insurer or any other person. Penalties include imprisonment and/or nes. In addition, an insurer
may deny insurance benets if false information materially related to a claim was provided by the applicant.
Florida – Any person who knowingly and with intent to injure, defraud, or deceive any insurer les a statement of claim or an
application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Idaho – Any person who knowingly, and with intent to defraud or deceive any insurance company, les a statement
of claim containing any false, incomplete, or misleading information is guilty of a felony.
Indiana – A person who knowingly and with intent to defraud an insurer les a statement of claim containing any
false, incomplete, or misleading information commits a felony.
Kentucky – Any person who knowingly and with intent to defraud any insurance company or other person les a
statement of claim containing any materially false information or conceals, for the purpose of misleading, information
concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.
Louisiana – Any person who knowingly presents a false or fraudulent claim for payment of a loss or benet or
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to nes
and connement in prison.
Maine – It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for
the purpose of defrauding the company. Penalties my include imprisonment, nes, or a denial of insurance benets.
Maryland – “Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or b
enet or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and
may be subject to nes and connement in prison.”
Massachusetts – Any person who knowingly presents a false or fraudulent claim for payment of a loss or benet or
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to nes
and connement in state prison.
Minnesota – A person les a claim with intent to defraud, or helps commit a fraud against an insurer, is guilty of a crime.
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C-5082(8/21)
New Hampshire – Any person who, with a purpose to injure, defraud or deceive any insurance company, les a
statement of claim containing any false, incomplete, or misleading information is subject to prosecution or punishment for
insurance fraud, as provided in RSA 638:20.
New Jersey – Any person who includes any false or misleading information on an application for an insurance policy
is subject to criminal and civil penalties.
New Mexico – Any person who knowingly presents a false or fraudulent claim for payment of a loss or benet or know-
ingly presents false information in an application for insurance is guilty of a crime and may be subject to civil nes and
criminal penalties.
New York - GENERAL: Any person who knowingly and with intent to defraud any insurance company or other person
les an application for insurance or statement of claim containing any materially false information, or conceals for the
purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which
is a crime, and shall also be subject to a civil penalty not to exceed ve thousand dollars and the stated value of the
claim for each such violation
Ohio – Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or les a claim containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma – WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes
any claim for the proceeds of an insurance policy containing any false, incomplete, or misleading information is guilty
of a felony.
Oregon – Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) by submitting an
application, or (2) by ling a claim containing a false statement as to any material fact thereto, may be committing a fraudulent
insurance act, which may be a crime and may subject the person to criminal and civil penalties.
Pennsylvania – Any person who knowingly and with intent to defraud any insurance company or other person les an
application for insurance or statement of claim containing any materially false information or conceals for the purpose
of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime
and subjects such person to criminal and civil penalties.
Puerto Rico – Any person who, knowingly and with the intent to defraud, presents false information in an insurance
request form, or who presents, helps or has presented a fraudulent claim for the payment of a loss or other benet,
presents more than one claim for the same damage or loss, will incur a felony, and upon conviction will be penalized
for each violation with a ne no less than ve thousand (5,000) dollars nor more than ten thousand (10,000) dollars,
or imprisonment for a xed term of three (3) years, or both penalties. If aggravated circumstances prevail, the xed
established imprisonment may be increased to a maximum of ve (5) years; if attenuating circumstances prevail, it may
be reduced to a minimum of two (2) years.
Rhode Island – Any person who knowingly presents a false or fraudulent claim for payment of a loss or benet or
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to nes and
connement in prison.
Tennessee – It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company
for the purpose of defrauding the company. Penalties include imprisonment, nes, and denial of insurance benets.
Texas – Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime
and may be subject to nes and connement in state prison.
Utah – Any person who knowingly presents false or fraudulent underwriting information, les or causes to be led a
false or fraudulent claim for disability compensation or medical benets or submits a false or fraudulent report or billing
for health care fees or other professional services is guilty of a crime and may be subject to nes and connement in
state prison. Utah Workers Compensation claims only
Virginia –
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company
for the purpose of defrauding the company. Penalties include imprisonment, nes and denial of insurance benets.
Washington – It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for
the purpose of defrauding the company. Penalties include imprisonment, nes, and denial of insurance benets.
West Virginia – Any person who knowingly presents a false or fraudulent claim for payment of a loss or benet or
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to nes and
connement in prison.
In All Other States – Any person who, with intent to defraud or knowing that he is facilitating a fraud against an
insurer submits an application containing a false or deceptive statement may be guilty of insurance fraud.