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Complete this Notification Form as soon as you are notified of a client's death.

State statutes require us to supply claim forms to the beneficiary within 10 working days of notification of a claim. Advise us if you are not able to meet this commitment.

* Must be filled in
Your Contact Information:
Date:November 21, 2009
Your Name: *
Your Phone Number: * -   -   ext 
Your Email Address:
Your Fax Number: -   - 
Are you the Agent of Record?
YesNo
Insured's Information:
Insured's Name: *
Insured's Date of Birth: * (MM/DD/YYYY)

Policy Number(s) (list all):
Is this a survivorship policy?
NoYes 1st Death2nd Death
Date of Death: * (MM/DD/YYYY)
Cause of Death:
Name of the Country Death Occurred: *
USOther 
If Beneficiary is deceased, Date of Death: (MM/DD/YYYY)
Beneficiary Information:
Beneficiary Name: *
Beneficiary Phone Number: -   -   ext 

Address: *

Name, Address, Phone Number of Funeral Home (required for Express Claim only)
Who should send Claim Form to
Beneficiary? *
AgentClaims Dept

Notes:


Submit the email form  Clear the email form 

Insurance products are issued by: John Hancock Life Insurance Company (U.S.A.), Boston, MA 02116 (not licensed in New York) and John Hancock Life Insurance Company of New York, Valhalla, NY 10595.
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