Burial Insurance Beneficiary Statement Affidavit
Policy Information
Insurance Company Name
Policy Number
Deceased's Full Name
Date of Birth
Date of Death
Beneficiary Information
Beneficiary Full Name
Relationship to Deceased
Mailing Address
City
State
Zip Code
Phone Number
Email
Affidavit Statement
I, the undersigned, hereby certify that I am the designated beneficiary for the above-mentioned policy and that the information provided is complete and accurate to the best of my knowledge.
Beneficiary Signature
Date
Notary Public (if required)