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It is designed to collect critical information regarding the deceased insured, including date of birth, Social Security number, date and cause of death, and relevant policy details. The form also captures contact information for the claimant or next of kin. Additionally, it includes essential regulatory notices concerning the Foreign Account Tax Compliance Act (FATCA) and mandatory IRS tax withholding requirements for business, trust, or estate entities receiving disbursements without proper W-9 or W-8 documentation. The form provides clear instructions for submission to the Claims Department in Charlotte, NC, ensuring that all necessary data is captured to initiate the life insurance claims process efficiently and in compliance with federal tax regulations.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/first-notice-of-death-claim-usfl/284127/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/first-notice-of-death-claim-usfl/284127.png","ImageObject",442,249,{"name":88,"@type":89},"Lute","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-30","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":8},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required regarding the deceased insured?","Question",{"text":108,"@type":109},"You must provide the full name, date of birth, Social Security number, date of death, place of death, and the cause of death.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What are the FATCA requirements mentioned in the form?",{"text":113,"@type":109},"Under FATCA, taxable disbursements to entities such as businesses, trusts, or estates may be subject to 30% withholding if proper IRS Form W-9 or W-8 documentation is not provided to the insurance company.",{"name":115,"@type":106,"acceptedAnswer":116},"Where should the completed claim form be sent?",{"text":117,"@type":109},"The form must be returned to the Claims Department of the U.S. Financial Life Insurance Company at PO Box 1419, Charlotte, NC 28201-1419.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},284127,1789628264,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":8,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":125,"read_time":4},137454149569,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","First Notice of Death Claim  \nForm CL 01 (10/15)  \nPLEASE PRINT  \n\n| Name of Deceased Insured Date of Birth and Social Security Number |  |\n| --- | --- |\n| Date of Death Place of Death/City & State Cause of Death |  |\n| Policy Number(s) Policy Face Amount(s) and Effective Date(s) Who has policies? |  |\n| Name of Caller and Relationship to Deceased\u003Cbr>Daytime Phone No. | If not relative, next of Kin information\u003Cbr>Name:   Address:   |\n|  |  |\n|  | Telephone:   |\n| Address to mail claim package: |  |\n| Additional Information: |  |\n| If married, please provide Spouse’s name. If spouse is deceased, please provide date of death. |  |\n| Please be advised: Due to IRS implementation of the Foreign Account Tax Compliance Act (FATCA), taxable disbursements made to entity (business, trust or estate) owners/payees may be subject to 30% withholding if proper documentation is not on file. Proper documentation is considered to be a properly completed and signed IRS Form W-9 for domestic entities. Foreign entities are expected to submit a properly completed and correct type of IRS Form W-8 . In the event proper documentation is not on file with AXA US (AXA Equitable, MLOA & USFL), we will withhold the required 30% upon disbursement. For further details regarding the FATCA rules and regulations and how disbursements may be affected, please contact your tax advisor. |  |\n\nRETURN FORM TO: Claims Department, U.S. Financial Life Insurance Company, PO Box 1419, Charlotte, NC  \n28201-1419, Phone: 800-959-3894, Fax: 855-784-1586","cbCaitpzbhSyKUr5","https://ap.wps.com/l/cbCaitpzbhSyKUr5","pdf",127967,"English","# Deceased Insured Information\n## Policy and Claimant Details\n## Tax Compliance and FATCA Requirements\n## Submission Instructions","[{\"question\":\"What information is required regarding the deceased insured?\",\"answer\":\"You must provide the full name, date of birth, Social Security number, date of death, place of death, and the cause of death.\"},{\"question\":\"What are the FATCA requirements mentioned in the form?\",\"answer\":\"Under FATCA, taxable disbursements to entities such as businesses, trusts, or estates may be subject to 30% withholding if proper IRS Form W-9 or W-8 documentation is not provided to the insurance company.\"},{\"question\":\"Where should the completed claim form be sent?\",\"answer\":\"The form must be returned to the Claims Department of the U.S. Financial Life Insurance Company at PO Box 1419, Charlotte, NC 28201-1419.\"}]","First Notice of Death Claim - USFL | PDF"]