NGL Trust Claim Form

If the deceased received Medicaid benefits, excess proceeds from this policy may be subject

State Medicaid Office or an elder law attorney for details.

FUNERAL DIRECTOR AUTHORIZATION (applicable only if a portion of proceeds are payable to funeral home) recovery. Contact

Authorization Of Payment For Funeral Goods And Services

As the person legally responsible for the funeral arrangements of the deceased Insured, I certify that the Funeral Provider provided the requested funeral goods and services on behalf of the insured, and authorize payment of the above amount to the Funeral Provider for the funeral goods and services furnished. I understand that the Company reserves the right to request a certified copy of the death certificate before benefits are paid. Thus, I understand it is important to retain original versions of these forms. I acknowledge that I have read the fraud warning statement on the last page of this form.

Signature of Person Legally Responsible for Making the Funeral Arrangement (Not the Funeral Director) Date Complete ONLY if benefits to be paid to BENEFICIARY (not applicable for policies assigned to the NGL Funeral Expense Trust)

Name of Trust Beneficiary(ies) for Excess Proceeds Relationship to Insured Street/Mailing Address City State Zip __________________________________________

Signature of Trust Beneficiary(ies) Date

Claim Requirements:

1. Copy of Death Certificate listing cause and manner of death if:

• Claim form is signed in IN, KY, LA or MA

• OH & WI (must be submitted to NGL within 60 days)

• If cause of death is not natural (accidental, suicide or homicide)

• In TN (if claim is over $15,000)

• All contestable claims

• Whenever a beneficiary is filing direct independent of the funeral home.

2. Copy of the Funeral Bill (if paid in full, copy of proof of payment)

3. This completed form FET-EPT 11-21