FOR OSGLI USE ONLY
CLAIM FOR DEATH BENEFITS
(Servicemembers’ Group Life Insurance)
(Veterans’ Group Life Insurance)
RETURN COMPLETED FORM TO:
OFFICE OF SERVICEMEMBERS’ GROUP LIFE INSURANCE
213 Washington Street
Newark, New Jersey 07102-2999
NOTE: THIS FORM IS NOT TO BE USED FOR NATIONAL SERVICE LIFE INSURANCE (NSLI) Policy Numbers Prefixed by V, H, RH, RS, W, J, JR and JS or
UNITED STATES GOVERNMENT LIFE INSURANCE (USGLI) Policy Numbers Prefixed by K
1. NAME OF DECEASED (First, middle, last) 2. SOCIAL SECURITY NO. 3. DATE OF DEATH
4. BRANCH OF SERVICE 5. DUTY STATUS ON DATE OF DEATH (If known) 6. IF DISCHARGED OR SEPARATED, GIVE DATE
(If known) (Month,day,year)
PLEASE READ THE IMPORTANT INFORMATION AND INSTRUCTIONS ON REVERSE BEFORE COMPLETING.
7. NAME (First, middle, last)
PART I - INFORMATION CONCERNING CLAIMANT
8. RELATIONSHIP TO
9. DATE OF BIRTH
(Month, day, year)
10. SOCIAL SECURITY NUMBER
11A. DATE OF MARRIAGE(Mo., day, yr.)
NOTE: Complete Items 11A through 14C if you are the widow or widower of deceased.
11B. PLACE OF MARRIAGE (City and State) 12. DID MARRIAGE CONTINUE UNTIL DATE OF DEATH?
13A. DID DECEASED HAVE ANY PREVIOUS
14B. PREVIOUS MARRIAGE TERMINATED
NOTE: - If you are not the named beneficiary, widow or widower of the deceased, complete Parts II and III.
14C. DATE PREVIOUS MARRIAGE TERMINATED
(If divorced within last 5 years attach copy of the
(If "Yes" complete
14B and 14C)
14A. DID YOU HAVE ANY PREVIOUS MARRIAGES?
PART II - INFORMATION CONCERNING NEXT-OF-KIN OF DECEASED
13C. DATE PREVIOUS MARRIAGE TERMINATED
(If divorced within last 5 years attach copy of the
List below the name, age, relationship, and address of: (Check appropriate places below)
(a) Widow or Widower, None Death Give Date
If none, was insured ever married? Yes No If yes, did marriage terminate by: Divorce Give Date
(b) If there is no surviving widow or widower, list all the children of the deceased. Include any adopted child or illegitimate child stating
which class it is and list the descendants of any deceased child or children. If none, check here
(c) If there are no children or descendants of children, list the surviving parent or parents.
Is father deceased? Yes No Is mother deceased? Yes No
(d) If there are no survivors within the degrees indicated in (a) through (c), list below the next of kin who may be capable of inheriting
from the deceased (brothers, sisters, descendants of deceased brothers, sisters, etc.) .
13B. PREVIOUS MARRIAGE TERMINATED
(If "Yes" complete 13B and 13C)
15B. AGE 15C. RELATIONSHIP TO DECEASED 15D. ADDRESS
NOTE - Complete Items 16 and 17 ONLY if any of the persons listed above are under age 21.
16. NAME AND ADDRESS OF GUARDIAN FOR ANY MINOR CHILDREN LISTED ABOVE IF ONE
HAS BEEN APPOINTED BY THE COURT (Attach copy of appointment paper issued by court)
17. IF A GUARDIAN HAS NOT BEEN APPOINTED, WILL
ONE BE APPOINTED?
PART III - INFORMATION CONCERNING THE ESTATE OF THE DECEASED
18. NAME AND ADDRESS OF EXECUTOR OR ADMINISTRATOR, IF ANY, APPOINTED BY THE COURT
TO SETTLE THE ESTATE OF THE DECEASED
19. IF AN EXECUTOR OR ADMINISTRATOR HAS NOT
BEEN APPOINTED, WILL ONE BE APPOINTED?
I HEREBY CERTIFY that all statements in this claim are true to the best of my knowledge, information, and belief, and that no evidence necessary
to a settlement of this claim is suppressed or withheld. In the event the insured has not previously elected monthly installments, I request that the
Death Benefit be paid in: (Check one) One Sum 36 Equal Monthly Installments.
PART IV - CERTIFICATION BY CLAIMANT
WARNING - Any intentional false statement in this claim or willful misrepresentation relative thereto is subject to punishment by a fine of not more than
$10,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001)
20. SIGNATURE OF CLAIMANT (Do not print) 21. ADDRESS (Number and Street, City, State and ZIP Code, Apt. No.)
SGLV 8283 JULY 1994
IF ADDITIONAL SPACE IS REQUIRED, ATTACH SEPARATE SIGNED
EXISTING STOCKS OF SGLV 8283, JAN 1991, WILL BE USED
23. DAYTIME PHONE NUMBER
INSTRUCTIONS TO CLAIMANTS
THIS FORM SHOULD BE USED WHEN THE DECEASED HAD INSURANCE IN FORCE UNDER SERVICEMEMBERS’ GROUP LIFE
INSURANCE (SGLI) OR VETERANS’ GROUP LIFE INSURANCE (VGLI)
PAYMENT OF DEATH BENEFITS
Under Servicemembers’ and Veterans’ Group Life Insurance death benefit payments must be made in the following
To the beneficiary named in writing by the insured; if none, the insurance is payable to
the widow or widower of the insured; if none, it is payable to
child or children in equal shares with the share of any deceased child distributed among the descendants of that
child; if none, it is payable to
parent(s) in equal shares; if none, it is payable to
a duly appointed executor or administrator of the insured’s estate, and if none, to
other next of kin.
COMPLETION OF CLAIM FOR DEATH BENEFITS
It is important that all requested information be furnished. Omission or incomplete answers will delay settlement of the claim.
All information should be typed or printed in ink, except the signature.
ITEM 1.Show full name of the deceased servicemember or veteran.
ITEM 2.Show Social Security number of deceased. If the deceased did not have a Social Security number,
show service number.
ITEM 3.Show date of death of deceased.
ITEMS 4, Show branch of service, duty status on date of death (if known), and date of discharge or
5 AND 6 separation (if known) of deceased.
ITEMS 7, 8, Show your full name, relationship to deceased, your date of birth and Social Security number.
9 AND 10.
If you were married to the deceased when he/she died, but were not named as his/her beneficiary, complete Item 11A
through 14C as applicable.
If you were not married to the deceased when he/she died and were not specifically named as his/her beneficiary, complete
Part II through 15D. Be sure to provide the required information as to the deceased’s marital status and any children. In
Items 15A through 15D give the information about persons indicated in the answers to the preceding questions. In Part II
use a separate signed sheet if necessary.
Complete Part III if you were not named as the insurance beneficiary, were not married to the deceased at his/her death
and are not a parent of the deceased.
Part IV must be completed by all claimants.
If the deceased died while on active duty or while a member of a Reserve or National Guard Unit, the Office of
Servicemembers’ Group Life Insurance will be furnished with proof of death by the Uniformed Service. In all other situations,
the claimant must submit a certified copy of the Certificate of Death.
Members performing duty on a full-time basis usually over 30 days and qualified members of the Ready Reserve are
insured for 120 days following separation. Members totally disabled at separation may be insured for up to one year
following separation as long as total disability continues. If the insured died while covered following separation from service,
the claimant must also submit a copy of a report of separation, DD 214.
You will be informed if it becomes necessary to submit other evidence.
If you need assistance in completing this claim form, contact your nearest Department of Veterans Affairs Office.