Life Claims Service Center P.O. Box 105448 Atlanta, GA 30348-5448 Phone: 800-813-5682 (2022)

Life Claims Service Center P.O. Box 105448 Atlanta, GA 30348-5448 Phone: 800-813-5682

Life Claims Service CenterP.O. Box 105448Atlanta, GA 30348-5448Phone: 800-813-5682Fax: 877-305-3901Email:[emailprotected]Please accept our condolences on your recent loss. We realize that this is a difficult time for you, and we will do our bestto make sure that all of your dealings with us are handled in a professional, caring and timely manner.We know that during a confusing time like this, even simple decisions can seem huge. And no matter how well youmay have prepared, you may feel that you are forgetting something important. So we have provided you with someinformation that may be of help: “Losing a Loved One: A List of Reminders” is a list of things that may need to be takencare of in the coming months, from dealing with pets to canceling credit cards. We hope you’ll find this checklist useful.To help us process your claim quickly, please complete the enclosed Beneficiary Claim Form and mail it to us as soon aspossible. For your convenience, we have also enclosed an instruction sheet called “A Guide to Help You Complete YourBeneficiary Claim Form” to help answer any questions you may have. If needed, feel free to call our Life Claims ServiceCenter at 800-813-5682, Monday through Friday, 8:30 am – 8:00 pm Eastern Time.Our Access Advantage account is a checkbook program that is provided to you without cost as an additional benefit.As soon as your claim is received and approved, we will send you an Access Advantage account kit that will includeyour checkbook and more detailed information on how to access your funds. Life insurance proceeds of $10,000 andmore are paid through our Access Advantage account program. The funds will be available immediately, and you maywithdraw the total amount, or leave a full or partial balance in the account where it will earn competitive money marketinterest rates. The Access Advantage Account program is set up for your convenience and is provided at no cost to you.If you have a question specifically related to this program, please call the Access Advantage account Service Centerat 800-551-7564.Anthem Life Insurance Company is a strong, stable industry leader, and we take our responsibility very seriously.We are committed to serving you in a caring and compassionate manner.Sincerely,Anthem Life Insurance CompanyLife and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association.®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks ofthe Blue Cross and Blue Shield Association.13007MUMEN 3/10Losing a loved one: A list of remindersLosing a loved one has a way of making anyone feel unprepared.Suddenly, there are a hundred things to do and remember.We hope you’ll find this checklist useful.ImmediatelyDiscuss medical issues with doctors. Should there be an autopsy?Was the deceased an organ/tissue donor?Determine whether the deceased wrote a letter of intent or madepre-arrangements for funeral, cremation or burial, including whetherany services were pre-paid.Contact funeral home or provider about disposition of the body.Notify family and close friends. Don’t be shy about asking for help withphone calls. (The contact chart on the back of this sheet may help.)Preparing for funeral or memorial serviceMake planning decisions for a funeral or memorial service, includingwho will be billed.Gather the deceased’s information for the funeral home — includingID numbers and personal history — so they can issue a death certificate.You can also use this information for an obituary or paid death notice.Ask friends and family to handle notifying people of the service, andto provide travel assistance.Send obituary or paid death notice to local papers and any otherappropriate publications.Decide how many death certificates you’ll need.Family and household issuesProvide for the immediate care of deceased’s dependents and otherurgent matters.If the deceased had any pets, arrange for their feeding and care, anddecide whether a new living situation is necessary.See to outstanding property matters, such as the deceased’s mortgage,rent and utilities.If the house is empty, arrange for a house sitter or put timers on thelights and TV. Plan for mail pickup and cancel newspaper delivery.Remove any valuables such as jewelry, small antiques and wallets.Locate the deceased’s calendar and cancel scheduled appointments.Cancel services such as meal deliveries, home health aides or volunteers.12913CAMEN 3/10Personal and financial mattersOther benefitsFind important documents, including:− will or living trust− deeds− titles− licenses− insurance policies− financial records− tax returns− identification papers− disability claims− military certificatesCheck all insurance policies for death-related benefits.Ask frequent flyer programs about transferring mileage.Contact the attorney and/or executor named in the will to handle probatecourt and estate matters.Transfer assets and property titles if you are a surviving spouse, partneror dependent.Open individual bank accounts if you are a surviving spouse or partner.Locate any safe deposit box(es).Notify Social Security of death andfile for any death or survivor benefitsthat may apply: 800-772-1213.Contact U.S. Department of VeteransAffairs for benefits if the deceasedwas a veteran: 800-827-1000 orwww.va.gov.If the deceased was an activepeace officer or in the military,contact local representatives.Employment issuesContact accountant or tax advisor about filing taxes, preparing a budgetand valuing assets.Investigate possible benefits throughsocial or fraternal organizations,unions, mortgage companies andcredit cards.Contact the deceased’s employerabout benefits, unpaid compensationand retirement/investment accounts.Ask about any unused vacation orpersonal time, unpaid commissionsor bonuses, etc.Contact insurance agents to change your policies and beneficiaries,if necessary.Cancel the deceased’s individual credit cards; but don’t remove thename from joint accounts for six months.Change all home utilities to your name if you shared a household withthe deceased.Update your will and consider preparing your own funeral or memorialpre-arrangements.People to contactNamePhone numberNameLife and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association.® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.Phone numberA Guide to Help You CompleteYour Beneficiary Claim FormAnthem Life Insurance Company has begun preparingyour claim. To complete the claim process, please sendus the following:1. A completed Beneficiary Claim Form fromeach beneficiary. (You may photocopy theattached form if necessary.)Claims by an Estate or AssigneeFor claims by an estate or assignee, the executor oradministrator filing the claim must sign the ClaimForm and submit certified copies of the appointmentpapers. Please remember to include the estate’sIdentification Number.2. A certified copy of the death certificate.3. A copy of the Enrollment Form or BeneficiaryDesignation Form on which the insurednamed his or her beneficiaries.Section 1Information About the BeneficiaryPlease be sure to complete this entire section. It’salso important to include your telephone number aswe may need to call you if we need more information.Social Security or Identification NumberIn most cases, Life benefits are not subject to incometax. However, because you may be earning taxableinterest under our Access Advantage account,the federal government requires us to obtain yourSocial Security Number or Taxpayer IdentificationNumber. If you do not provide us with your SocialSecurity Number or Taxpayer Identification Number,the federal government requires us to withhold aportion of any interest that we would otherwise payyou as a deposit against the taxes that may be due.Important: If you have been notified by the InternalRevenue Service that you are subject to backupwithholding tax, please check the “Yes” box after thequestion on the Claim Form.We may call you for more information if you are nota United States citizen and/or you reside in aforeign country.Assignment of BenefitsIf you have assigned any or all of the claim proceedsfor funeral/burial expenses, please include a copy ofthat assignment along with the itemized bill.If the policy proceeds have been assigned to a bankor financial institution, the Claim Form must besigned by an authorized representative of thatinstitution.Section 2Information About the Insured (the Deceased)Please complete this section for identificationpurposes. If Life coverage was issued within twoyears of the insured’s date of death, or if theinsured’s death was due to an accident and the policyprovided for accidental death benefits, we may askyou for additional information.Section 3Signature and CertificationPlease sign the Beneficiary Claim Form in the samemanner that you sign your checks. This is importantas your signature may be used to verify your AccessAdvantage account checks. Please note that you willalso be certifying, under penalty of perjury, that yourSocial Security Number or Taxpayer IdentificationNumber and backup withholding status are correct.If you have additional questions about theAccess Advantage account, please callour Access Advantage account ServiceCenter at 800-551-7564, Monday throughFriday, 8:30 am – 5:00 pm Eastern Time.Life and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association.®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks ofthe Blue Cross and Blue Shield Association.12909MUMEN 3/10Beneficiary Claim FormPlease return this beneficiary claim form together with an official certified copy of the death certificate.Please type or print your name and address exactly as youSection 1: Information About the Beneficiarywould like them to appear on your checks.qqNameSex Male FemaleFirst Middle Initial LastAddressHome Phone ()Street Apt. No.Daytime Phone ()City State ZIPDate of BirthBeneficiary’s Social Security or Taxpayer Identification NumberMonth Day YearHave you been notified by the Internal Revenue Service that you are subject to backup withholding tax as aresult of failure to report all interest or dividends? Are you exempt from backup withholding tax? Are you a United States citizen? (If No…) Do you reside in a foreign country? In what capacity are you making this claim? Beneficiary’s Relationship to the Insuredq Yes q Yes q Yes q Yes q Beneficiary q Trustee q Spouse q Parentq Noq Noq Noq Noq Executor/Administrator (for claims by an estate or assignee)q Other ______________________________q Childq Other ______________________________Section 2: Information About the Insured (the Deceased)Name ____________________________________________________________________ Social Security Number ______________First Middle Initial LastDate of Birth __________________________MonthDayYearDate of Death __________________________Month DayYearAnthem Life Insurance Policy Number _________________________________________________________Section 3: Signature and CertificationI certify, under penalty of perjury, that the Social Security Number or Taxpayer Identification Number and Beneficiary’s backupwithholding status information in Section 1 is complete and correct. I understand that my signature may be used for signatureverification for certain purposes, including for my Access Advantage account.Signature _______________________________________________________________________________________________(Sign as you would a check. Your signature may be used for check verification.)It is a crime to knowingly, with intent to defraud, file a statement of claim containing materially false or misleading information, orto conceal any material fact. Untrue or misleading statements may subject persons to criminal prosecution and civil penalties.For Use by Anthem Life OnlyExaminerClaim NumberDate Approved/DeniedBranch Total Benefit and InterestReturn this completed form to:Anthem Life Insurance CompanyLife Claims Service CenterP.O. Box 105448Atlanta, GA 30348-5448800-813-5682 Fax: 877-305-3901Email: [emailprotected]This claim form may have been sent before Anthem Life Insurance Company has determined whether any Life coverage was in force at the time of death; whether any proceeds arepayable; and to whom any proceeds are payable. Anthem Life Insurance Company retains its rights to make these determinations.Life and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a registeredtrademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.Si usted necesita ayuda en Español para entender este documento, puede solicitarlo sin ningun costo adicional llamando al número de servicio al cliente que se encuentra eneste documento.12902MUMEN 3/10

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