Policy Holder ID Number
Deceased's First Name
Deceased's Last Name
Deceased's other name (If Applicable)
Deceased's Date of Birth
MaleFemale
Deceased's Street Address
Deceased's Street Address Line 2
City
Postal/ Zip Code
Deceased's Date of Death
Place of Burial
Name
Phone Number
Email
Relationship
Applicant/ Authorized Person's Signature
Date of Signature
Please upload Applicant Photo ID, Deceased Photo ID & UMCBF Member’s Death Certificate
