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* Must be filled in
Your Contact Information:
Date:September 09, 2010
Your Name: *
Your Phone Number: * -   -   ext 
Your Email Address:
Your Fax Number: -   - 
Your Relationship to the Insured?
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 Contact Information (if different from "Your Contact Information"):
Beneficiary Name: *
Beneficiary Phone Number: -   -   ext 

Address: *
Who should receive the Claim Form? *
BeneficiaryOther

Name and Mailing Address for mailing claim form (required if "Other" was selected in previous question):
Notes:


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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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