External Death Claim – Tip Friendly Society

OVERVIEW

This form outlines all requirements to process an External Death Claim. External death includes accidental death or death occurring outside of a medical facility and requires multiple insurer and reinsurance documents. Please review all instructions carefully. All forms listed below must be downloaded, completed by the appropriate authority, and uploaded before submission. Incomplete or unsigned documents will delay the processing of your claim.

Forms required are:

1. External Death Claim Form
2. Death Claim Reinsurance Requirement Form
3. Certificate of Death – Guardian EB201
4. Guardian Life Limited Electronic Funds Transfer Form (EFT GEN 283)}
5. JCIA Death Claim Requirements
6. Sagicor Claimant’s Statement
7. Sagicor Proof of Death – Physician’s Statement

MEMBER DETAILS

*Member Number

*TRN

Phone Number

*Full Name

*Email

*Alternate Phone Number

*Current Address

PROOF OF DEATH CLAIMANT STATEMENT

*Name of Insured Person (if married woman, give maiden name also)

*Teacher Name

*Teacher Number

*School Name

*School Number

*Place Of Birth

Date Of Birth

*Residence at Death

Date Of Death

Occupation at Time of Death

Date last time worked full time at full pay

Cause of Death

When did Insured first complain or give other indications of last illness?

When did Insured first consult a physician for last illiness?

List all Physicians who attended the Insured during last illness and during three years prior thereto:

Dates:

Physician Name

Address

*Phone Number

Has Insured other Life Insurance? If so, in what Companies and for what amounts?

Company

Policy Number

Policy Date

Amount

Company

Policy Number

Policy Date

Amount

Company

Policy Number

Policy Date

Amount

In what capacity do you claim this Insurance?

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