Legal Death Verification Form

LEGAL DEATH VERIFICATION FORM

This Legal Death Verification Form ("Form") is made and entered into as of Effective Date: , by and between Requesting Party Name: (Requesting Party), and Certifying Authority Name: (Certifying Authority).

RECITALS

WHEREAS, Requesting Party requires formal verification of the death of the individual identified below for the purpose of processing legal, administrative, or benefit matters; and

WHEREAS, Certifying Authority is the official custodian of vital records or an authorized official with the legal authority to examine and certify death records issued in the jurisdiction identified below; and

WHEREAS, the parties desire to record in writing the facts certified by Certifying Authority and the terms under which Requesting Party may rely upon such certification.

NOW, THEREFORE, in consideration of the mutual covenants and agreements set forth herein, the parties agree as follows:

1. DECLARATION OF DECEDENT

Decedent Full Legal Name:

Date of Birth:

Date of Death:

Place of Death (Facility or Address):

Death Certificate Number: Issuing Jurisdiction:

Decedent Identifier (Last 4 of SSN or other ID):

2. CERTIFICATION BY CERTIFYING AUTHORITY

Certifying Authority hereby certifies, under penalty of perjury to the best of its knowledge and based upon its official records, that the Decedent identified above is recorded in the official death records maintained by Certifying Authority as deceased on the Date of Death set forth above and that the Death Certificate Number and Issuing Jurisdiction identified above correspond to those official records.

Certifying Authority further certifies that it has examined the original or certified copy of the death record and that the certification provided is a true and correct representation of the information contained in the official record as of the Effective Date of this Form.

3. SCOPE OF RELIANCE AND USE

Requesting Party may rely on this certification solely for the internal purposes stated in the opening paragraph and for the adjudication of claims, termination of benefits, probate administration, or other lawful activities directly related to the legal status of the Decedent. Any use of the certified information for purposes not reasonably contemplated in this Form requires a separate written consent from Certifying Authority.

4. SUPPORTING DOCUMENTS

The following supporting documents have been presented to Certifying Authority and considered in issuing this certification. Describe documents, originals reviewed, and identification shown.

5. REPRESENTATIONS, WARRANTIES AND COVENANTS

Each party represents and warrants that it is duly authorized to enter into this Form and to perform its obligations hereunder. Certifying Authority represents that it has the legal authority to certify the death record described herein. Requesting Party represents that it will use the certified information only for the purposes expressly permitted in Section 3 and in compliance with all applicable privacy and records laws.

6. CONFIDENTIALITY AND DATA PROTECTION

Requesting Party shall maintain the certified information in a secure manner and shall not disclose the information to any third party except as required by law or as necessary to effectuate the purposes set forth in Section 3. Any permitted recipient must be informed of and agree to obligations of confidentiality at least as protective as those set forth in this Form.

7. INDEMNIFICATION

Requesting Party shall indemnify, defend and hold harmless Certifying Authority and its officers, employees and agents from and against all claims, liabilities, losses, damages, costs and expenses (including reasonable attorneys’ fees) arising out of or relating to Requesting Party’s misuse, unauthorized disclosure, or negligent handling of the certified information, except to the extent such claims arise from Certifying Authority’s gross negligence or willful misconduct.

8. FEES AND COSTS

If applicable, Requesting Party shall pay any reasonable fees charged by Certifying Authority for copying, certification, retrieval, or expedited processing of the death record. Parties acknowledge that fees charged by Certifying Authority are set in accordance with its schedule of charges.

9. NOTICES

Requesting Party Notice Address

Certifying Authority Notice Address

All notices shall be in writing and shall be deemed delivered when received in person, when electronic confirmation of delivery is obtained for an electronically transmitted notice, or three (3) business days after deposited in the United States mail, postage prepaid, certified mail, return receipt requested, addressed to the party’s notice address set forth above or to such other address as either party may designate in writing.

10. AMENDMENTS, WAIVER, COUNTERPARTS

This Form may be amended only by a written instrument signed by both parties. No waiver of any provision is effective unless in writing and signed by the party against whom the waiver is asserted. This Form may be executed in counterparts and by electronic signature, each of which shall be deemed an original, and all of which together shall constitute one and the same instrument.

11. GOVERNING LAW; SEVERABILITY; ENTIRE AGREEMENT

This Form shall be governed by and construed in accordance with the laws of the jurisdiction of the Issuing Jurisdiction identified above, without regard to conflict of law principles. If any provision of this Form is held to be invalid, illegal or unenforceable, the remaining provisions shall continue in full force and effect. This Form constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings and negotiations, whether written or oral.

12. MISCELLANEOUS

The headings used in this Form are for convenience only and shall not affect the interpretation of this Form. The obligations of the parties that by their nature would survive the termination of this Form shall survive.

Entity Type of Requesting Party: Individual Organization

Additional Remarks:

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