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STATEMENT ALONG WITH VERIFIABLE PROOF OF DEATH. PLEASE NOTE, ADDITIONAL INFORMATION MAY BE REQUESTED FROM THE INSURED S ESTATE, NEXT OF KIN OR PERSONAL REPRESENTATIVE. INFORMATION ON DECEASED LAST NAME FIRST NAME MIDDLE INITIAL MAIDEN/ALIAS/NICKNAME ADDRESS CITY COUNTY STATE ZIP SOCIAL SECURITY NUMBER DATE OF BIRTH RELATIONSHIP TO POLICYHOLDER: SPOUSE DEPENDENT OTHER The undersigned hereby applies to Aflac or payment of said insurance and agrees that the written statemen.

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