Report a Life Claim

About You:

Your relationship to Deceased:*
Please Select... Spouse Child Parent Sibling Friend Funeral Home Attorney Other
First and Last Name:*
Email:*
Address:*
City, State Zip:*
Phone Number:*

About the Deceased:

First Name:*
Last Name:*
State of Residence:*
- Please select a state - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other

Date of Birth:*
Date of Death:*
Cause of Death:* Please Select... Cancer Endocrine, Metabolic and Blood Diseases Mental Disorders and Nervous System and Sense Organs Heart and Circulatory System Diseases Respiratory System Diseases Digestive System Diseases Accidents and Violence Suicide Unknown

Do you currently have any funeral home information?   No Yes

Other Info:

Please enter any additional information you feel will be helpful for the claims process here: