Finance – People Strategy Group



Death Claim Form

|Policy |

| |

|Name of Deceased |

| |

|Date of Birth | |Date of Death | |

| |

|Date on which deceased joined the Company |

| |

|Date on which deceased joined the Scheme |

| |

|Date on which deceased last worked |

| |

|Date of diagnosis of illness resulting in death (if applicable) |

| |

|Salary at date of death |

| |

|Sum Insured |

| |

|Please return the completed form with the following documents: |

|Original Birth Certificate |Yes |No |

|Original Death Certificate |Yes |No |

|Additional information (if applicable):- |Yes |No |

|Copy of Post Mortem | | |

|Declaration: |

|I/we declare that the statements and particulars contained in the proposal are true and that I/we have not mis-stated |

|or suppressed any material facts. |

|I/we undertake to inform Underwriters of any material alteration to these facts occurring before completion of the contract of insurance. |

|Signature of Company Representative: | |

|Position: | |

|Dated: | |

-----------------------

Beazley Group plc

Plantation Place South

60 Great Tower Street

London EC3R 5AD

Phone +44 (0)20 7667 0623

Fax +44 (0)20 7674 7100



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