Claims Support

Claim Form - Life Claimant Statement

For all states except New York. Fill this out to request payment of the death benefit.

Claim Form - Life Claimant Statement New York

For New York only. Fill this out if deceased lived, purchased coverage, or died in NY. You may also fill this out if the beneficiary lives in NY. You’ll fill this out to request payment of the death benefit.

HIPAA

This is your authorization allowing us to obtain the insured’s medical information.

Supplemental Claims

Fill this out if the insured’s death occurred within the first two years of the policy issue date or reinstatement date.

Direct Deposit Authorization

Fill this form out if you’d like the payment to be deposited directly to your bank account.

Affidavit of Next of Kin form

This is a sworn written statement that identifies all blood and adopted relatives of the deceased. Fill this out and note that this statement requires notarization.

Reinstatement Form - Florida

Fill out this form if your policy was purchased in Florida, has lapsed and you would like to reinstate it.  

Reinstatement Form - Delaware, North Dakota and South Dakota

Fill out this form if your policy was purchased in either Delaware, North Dakota or South Dakota, has lapsed and you would like to reinstate it.  

Reinstatement Form - Nationwide

Fill out this form if your policy was purchased in any other state aside from Florida, Delaware, North or South Dakota, has lapsed and you would like to reinstate it.  

A contestable claim is a life insurance policy that is less than two years old when the insured dies (based on the policy issue date or reinstatement date). When this type of a claim is filed, we make sure that the information on the application was true and correct when the policy was issued. This is an industry standard and a rule that all life insurance companies must follow. Assuming a policyholder supplied accurate information on the application, there should be nothing to worry about.

The reason it can take so long is that we need certain information like the insured’s medical records. You can help us move things along by contacting medical providers directly and asking them to send us the information about the insured. In some cases, they may require you to fill out an additional authorization form specific to their office.

For your security, we currently only accept completed claims forms through the mail or fax. If you'd like to overnight your forms to us, you made do so at 777 Research Dr, Lincoln, NE 68521.

Each beneficiary needs to submit an individual claim kit that includes all necessary paperwork. We’ll pay each beneficiary their proceeds separately as we receive the required claim documents from each of them. 

There are two different ways to do this. The first way is to contact the funeral home who provided the services. The second way is to order copies yourself. You can contact the state or local health department in the state or county that the individual resided in at the time of death.

They are medical retrieval companies that we use to help us in obtaining the information needed to review your life insurance claim. 

Many times, medical facilities and providers need verification that the individual signing the HIPAA has the authority to do so on behalf of the deceased. Once you have completed the affidavit, we will send it to the medical provider(s) to allow them to release the records.

The next of kin is the legally married spouse followed by children. Some providers may require the informant on the death certificate sign the affidavit. 

If your claim is contestable, our team will send you a claim packet within 3 to 5 business days which will include:

• Claim form
• HIPAA – Authorization for Release of Medical Information
• Supplemental Contestable claim form
• Next of Kin Affidavit

You will need to return these completed documents along with a certified death certificate. Once these items are received, we will be able to begin our review process which will include collecting information concerning the insured's medical history prior to the application date. Information may need to be obtained from multiple medical providers. Some may even require you to provide additional information to release their medical records. These additional requirements may include:

• Completing the facility's own authorization form
• Next of Kin Affidavit
• Copy of your photo ID
• Estate documentation 

Each medical providers timeframe on submitting medical records to Lumico varies. We will continue to follow up with the facilities regularly until the information is received. However, you may be able to help expedite obtaining the medical records by contacting the medical office directly and request they forward the medical records to Lumico. Once we have received all requested medical records, we will finish the review process. 

If the primary beneficiary is deceased, we will require a copy of the death certificate.

• If the primary beneficiary died prior to the insured, any benefits payable will be paid to the remaining primary beneficiary(ies). If there are no other primary beneficiaries, then any benefits payable will be paid to the contingent beneficiary.
• If the primary beneficiary died after the insured, the benefits are payable to the Estate of the Beneficiary. 

If the beneficiary is the Estate of the insured, we will require evidence of the court approved legal representative over the Estate. Please provide the Tax ID number of the Estate of the insured. 

If the beneficiary is a trust, we will require a copy of the trust agreement and any amendments, including the signature page. Please note the Trustee Certification section of the claim form will also need to be completed by all trustees. Please use the trust's name when completing the claimant information section of the claim form and provide the Tax ID number of the trust. 

Our overnight mail address is:

777 Research Drive

Lincoln, NE 68521