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GROUP LIFE INSURANCE CLAIM FORM GROUP POLICYHOLDER S STATEMENT Group Policyholder s name Name of insured employee/member We certify that the above employee/member last worked as of Name of Deceased Amount of Insurance being claimed Name of beneficiary Dated at Certificate No. full-time part-time on or was retired disabled Relationship to insured if Dependant this day of by CLAIMANT S STATEMENT. Authorized Official Signature Claimant s name in full Your SIN No. Your date of birth Deceased s birth date Deceased s address I hereby certify that I am the beneficiary last appointed under Group Policy No. I hereby authorize any physician medical practitioner hospital clinic or other medical or medically related facility insurance company or other organization institution or person that has any records or knowledge of the health of name of deceased to give to The Empire Life Insurance Company or its reinsurers any and all information with reference to the health and medical history of the deceased and any hospitalization advice diagnosis treatment disease ailment or condition. A photocopy of this authorization shall be as valid as the original. Date of death ADDRESS WITNESS SIGNATURE Cause of death CLAIMANT SIGNATURE DOCTOR S STATEMENT To be completed if claim is for 75 000 or more. Authorized Official Signature Claimant s name in full Your SIN No. Your date of birth Deceased s birth date Deceased s address I hereby certify that I am the beneficiary last appointed under Group Policy No. I hereby authorize any physician medical practitioner hospital clinic or other medical or medically related facility insurance company or other organization institution or person that has any records or knowledge of the health of name of deceased to give to The Empire Life Insurance Company or its reinsurers any and all information with reference to the health and medical history of the deceased and any hospitalization advice diagnosis treatment disease ailment or condition. A photocopy of this authorization shall be as valid as the original. Date of death ADDRESS WITNESS SIGNATURE Cause of death CLAIMANT SIGNATURE DOCTOR S STATEMENT To be completed if claim is for 75 000 or more. of employed by Date of onset of last illness Age at death or date of birth of deceased If death was due to an accident suicide or homicide specify which and describe briefly Address of Deceased died on Principal Secondary Date you first attended deceased in last illness Name and Address of Doctor - PLEASE PRINT GLB-0055-ENG-05/11 Signature of Doctor Telephone Any cost incurred in the completion of this form is the responsibility of the claimant. GROUP LIFE INSURANCE CLAIM FORM GROUP POLICYHOLDER S STATEMENT Group Policyholder s name Name of insured employee/member We certify that the above employee/member last worked as of Name of Deceased Amount of Insurance being claimed Name of beneficiary Dated at Certificate No* full-time part-time on or was retired disabled Relationship to insured if Dependant this day of by CLAIMANT S STATEMENT.

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