WebName of other insurance company Policy Number If yes, name of family member If yes, to either question above, and the patient is a dependent child, please provide spouse’s date … WebIf you have Guaranteed Standard Issue Program coverage with Great-West Life this form will be used as notice of claim for that coverage as well. Provide your banking information or attach a void cheque if you are applying for short or long term disability benefits.

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WebForms. You will need to submit forms in order to allow us to perform an array of tasks on your Preneed Funeral or Final Expense insurance policies through Great Western … WebCLAIM FORM PART 1 – TO BE COMPLETED BY THE PLAN MEMBER PLAN NUMBER 138100 158100 168100 170205 170844 178100 2. Is this claim for treatment of a … WebGreat Western Insurance Company Claims Dept. P.O. Box 14410 Des Moines, IA 50306-3410 Claim Process Information: ... Death Benefit Claim Form P.O. Box 14410 Des Moines, IA 50306-3410 Phone: 1-800-733-5454 Website: www.gwic.com Signature of Beneficiary Date. Medical Information Authorization . detailed troop decontamination stations