Loss of Life Notification Email Form
  
Once we receive this information, we will send the necessary claim forms to you. Please return the completed claim forms, any additional claim information, and a certified death certificate to the address on the claim form. We regret that we are unable to accept these forms via fax.

Please Note: The information you enter on the online forms is transmitted to Colonial via e-mail. The transmission is not secure. As a result, the privacy of any Social Security number that you include on an online form cannot be guaranteed. To file your wellness claim by telephone, please call the Policyholder Service Center at 1-800-325-4368. You may submit the loss of life notification form by fax to 1-800-880-9325.
Claimant Information
Name of Person Filing Claim
Telephone Number
Email
Relationship to Deceased
Deceased Insured     Spouse     Child
Policyholder Information
Insured's Name
State
Policy Number
Social Security Number
Death Information
Date of Death
Cause of Death
Accidental Death Yes     No
Accidental Death Location
Complete If Deceased is Spouse or Child
Spouse/Child Rider Name
Spouse/Child Date of Birth
Spouse/Child Social Security Number
Send Forms To
Name
Address
City
State
Zip
Fax Yes     No
Fax Number
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Colonial Life & Accident Insurance Company is a subsidiary of Unum Group
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Colonial Life products are underwritten by Colonial Life & Accident Insurance Company. Coverage has exclusions and limitations that may affect benefits payable. Coverage may vary by state and may not be available in all states. See your representative for complete details. Colonial Life is the marketing brand of Colonial Life & Accident Insurance Company.