American Century Life Insurance Company
9120 South Toledo Avenue
Tulsa, OKlahoma 74137
Office 918-712-7770
Fax 918-712-7773
Death Claim
Name of Insured
Policy Number
Face Amount of Policy
Social Security Number
Date of Death
Date of Birth
Assignee or Beneficiary
Address
City, State and Zip
Phone Number
The Undersigned hereby makes claim to said insurance in the American Century Life Insurance Company.
The undersigned hereby authorized the said Insurance Company to request any information concerning the death of the insured that they may deem necessary. The undersigned hereby authorizes any physician or medical institution to provide such information when requested by the company.
Please Enclosed the Following:
The Policy or an Affidavit of Lost Policy
Copy of a certificate of Death
This Death Claim Form
Date
Funeral Director Signature
or
Beneficiaries Signature
Sworn and subscibed before me on this date
Notary Signature and Seal
Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
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