Printable Forms: FNIS Group Insurance, Death Claims Forms
Basic, Dependent Life and Optional Life Insurance
The following three forms must be completed and forwarded to First Nations Insurance Services’ office for processing in order to claim life benefits for either an employee or an eligible dependent’s death.
- Plan Sponsor must complete applicable section and return to First Nations Insurance Services’ office for processing. Section 1 must be completed in the event of the death of an employee and Section 2 must be completed in the event of the death of an eligible dependent.
Election of Method of Settlement and Physician's Statement/Claimant's Statement
- Each named beneficiary (trustee of each minor beneficiary) must complete an Election of Method of Settlement and Claimant’s Statement, then sign, date and return forms to First Nations Insurance Services’ office for processing.
Basic Accidental Death and Dismemberment and Voluntary Accidental Death and Dismemberment
Plan Sponsor/Member must notify First Nations Insurance Services, in writing, within 30 days of Accidental Death or Dismemberment.
- The Group Life/Accidental Death Claim Form—Employer’s Statement must be completed by the Plan Sponsor
- The Group Life/Accidental Death Notice of Claim form must be completed by each beneficiary designated by deceased plan member.
- The Claimant must have the Group Life/Accidental Death Claim Form Physician’s Statement completed by the Attending Physician.
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