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: ___________________________