SGLV 8283 Form

Claim for Death Benefits

(Servicemen’s Group Life Insurance)
(Veterans’ Group Life Insurance)

Return completed form to: Office of Servicemen’s Insurance, Newark, New Jersey 07102-2999

Note: This form is not to be used for National Service Life Insurance (NSLI) or United States Government Life Insurance (USGLI).

1. Name of deceased

2. Social Security number 3. Date of death

4. Branch of service

5. Duty status on date of death

Active duty Drilling reservist Discharged or separated Individual ready reservist

6. If discharged or separated, give date

PART I – INFORMATION CONCERNING CLAIMANT

7. Your name

8. Relationship to deceased

9. Date of birth

10. Social security number

Note — Complete Items 11A through 14C if you are the widow or widower of deceased.

11A. Date of marriage

11B. Place of marriage

12. Did marriage continue until date of death? Yes No

13A. Did deceased have any previous marriages? Yes No

13B. Previous marriage terminated by Death Divorce

13C. Date previous marriage terminated

14A. Did you have any previous marriages? Yes No

14B. Previous marriage terminated by Death Divorce

14C. Date previous marriage terminated

Note — If you are not the named beneficiary, widow or widower of the deceased, complete Part II and III.

PART II – INFORMATION CONCERNING NEXT-OF-KIN OF DECEASED

List below the name, age, relationship, and address of the appropriate next of kin.

a) Widow or widower None

If none, was insured ever married? Yes No

If yes, did marriage terminate by Death Divorce Give date

b) Children / descendants

If none, check here

c) Surviving parent or parents

Is father deceased? Yes No Is mother deceased? Yes No

d) Next of kin

15A. Name 15B. Age 15C. Relationship to deceased

15D. Address

Note — Complete Items 16 and 17 ONLY if any of the persons listed above are under age 21.

16. Name and address of guardian

17. If a guardian has not been appointed, will one be appointed? Yes No

PART III – INFORMATION CONCERNING THE ESTATE OF THE DECEASED

18. Name and address of executor or administrator

19. If an executor or administrator has not been appointed, will one be appointed? Yes No

PART IV – CERTIFICATION BY CLAIMANT

I hereby certify that all statements made in this claim are true to the best of my knowledge, information, and belief, and that no evidence necessary to a settlement of this claim is suppressed or withheld.

In the event the insured has not previously elected monthly installments, I request that the death benefit be paid in:

One Sum 36 Equal Monthly Installments

Warning — Any intentional false statement in this claim or willful misrepresentation relative thereto is subject to punishment by a fine of not more than $10,000 or imprisonment of not more than 5 years, or both.

If additional space is required, attach separate signed sheets.

Instructions to Claimants

This form should be used when the deceased had insurance in force under Servicemen’s Group Life Insurance (SGLI) or Veterans’ Group Life Insurance (VGLI).

Payment of Death Benefits

Under Servicemen’s and Veteran’s Group Life Insurance death benefit payments must be made in the following order:

• To the beneficiary named in writing by the insured; if none, the insurance is payable to
• the widow or widower of the insured; if none, it is payable to
• child or children in equal shares with the share of any deceased child distributed among the descendants of that child; if none, it is payable to
• parent(s) in equal shares; if none, it is payable to
• a duly appointed executor or administrator of the insured’s estate, and if none, to
• other next of kin.

Completion of Claim for Death Benefits

It is important that all requested information be furnished. Omission or incomplete answers will delay settlement of the claim. All information should be typed or printed in ink, except the signature.

Item 1. Show full name of the deceased serviceman, servicewoman or veteran.

Item 2. Show Social Security number of deceased. If the deceased did not have a Social Security number show service number.

Item 3. Show date of death of deceased.

Items 4, 5 and 6. Show branch of service, duty status on date of death (if known), and date of discharge or separation (if known) of deceased.

Items 7, 8, 9 and 10. Show your full name, relationship to deceased, your date of birth and Social Security number.

If you were married to the deceased when he/she died, but were not named as his/her insurance beneficiary, complete Item 11A through 14C as applicable.

If you were not married to the deceased when he/she died and were not specifically named as his/her insurance beneficiary, complete Part II through 15D. Be sure to provide the required information as to the deceased’s marital status and any children. In Items 15A through 15D give the information about persons indicated in the answers to the preceding questions. In Part II use a separate signed sheet if necessary.

Complete Part III if you were not named as the insurance beneficiary, were not married to the deceased at his/her death and are not a parent of the deceased.

Part IV must be completed by all claimants.

Evidence Required

If the deceased died while on active duty or while a member of a Reserve or National Guard Unit, the Office of Servicemen’s Group Life Insurance will be furnished with proof of death by the Uniformed Service. In all other situations, the claimant must submit a certified copy of the Certificate of Death.

Members performing duty on a full-time basis usually over 30 days and qualified members of the Ready Reserve are insured for 120 days following separation. Members totally disabled at separation may be insured for up to one year following separation as long as total disability continues. If the insured died while covered following separation from service, the claimant must also submit a copy of a report of separation, DD 214.

You will be informed if it becomes necessary to submit other evidence.

If you need assistance in completing this claim form, contact your nearest Department of Veterans Affairs Office.