Deceased Insured Name (First, Middle Initial, Last) Certificate Number/Policy Number Issue Date Deceased’s Information
Face Amount District Number Deceased’s Beneficiary(ies) / Relationship: Beneficiary Name
Relationship to Deceased
SURVIVORS Legal Name (First, Middle Initial, Last) Address (Street, City, State, Zip) Survivor Information
Social Security Number
Date of Birth
Relationship
Phone
Signature Legal Name (First, Middle Initial, Last) Address (Street, City, State, Zip) Survivor Information
Social Security Number
Date of Birth
Relationship
Phone
Signature Legal Name (First, Middle Initial, Last) Address (Street, City, State, Zip) Survivor Information
Social Security Number
Date of Birth
Relationship
Phone
Signature This is to certify that those listed are the only survivors of the deceased insured. Before me, a notary public in and said for county and state, personally appeared each of the above mentioned.
Subscribed and sworn to before me this ___ day of ______________, 20 ___ __________________________________ Notary __________________________________ County State
My commission expires _______________ SURVC 02/11
Page 1 of 1 www.gbu.org info@gbu.org 4254 Saw Mill Run Blvd. Pittsburgh, PA 15227-3394 412-884-5100 800-765-4428 Fax: 412-884-9815