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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