(Print your name, address and phone number here)

(Print the insurance company name and address here)

Attention: Customer Service—Request for benefits information

Dear Sir or Madam:

I am the beneficiary of the deceased person listed below.  Kindly notify me whether or not the deceased had a life insurance policy, individual annuity, or a pension plan in effect with your company.

Deceased Name _________________________________________

Address _______________________________________________

City _____________________ State ________ Zip Code________

Social Security Number: __________________________________

Date of Birth: ___________________

Date of Death: __________________

Sincerely,

_____________________ ___________

(Sign name here)                          (Date)

_____________________

(Print name here)