Burial Insurance Beneficiary Statement
for Minor Beneficiary

Please complete all applicable sections. Use additional sheets if necessary.

Policy Information

Policy Number
Deceased's Full Name
Date of Death

Minor Beneficiary Information

Beneficiary's Full Name
Date of Birth
Relationship to Deceased
Beneficiary's Address

Parent or Legal Guardian Information

Name of Parent/Guardian
Relationship to Beneficiary
Address
Phone Number

Payment Instructions

Requested Payment Method
Comments / Special Instructions

Certification & Authorization

I certify that the information provided above is true and complete to the best of my knowledge. If required, I am authorized as the parent or legal guardian to act on behalf of the minor beneficiary.
Signature of Parent/Guardian
Date