Life Insurance and Annuity Search Service - Consumer Request Form

Enter Requestor Information * Denotes required information

First Name

Middle Name

Last Name

Suffix

Day Phone

Night Phone

Address

Address 2

City

Zip/Postal Code

Country

State / Province

Requestor's relationship to the deceased (check all that apply)

Attorney

Beneficiary

Child (18 or Older)

Executor / Legal Rep

Sibling

Spouse

Other

Specify the requestor's relationship to the deceased

Provide any additional information

4000 characters remaining

Enter Deceased Information * Denotes required information

First Name

Middle Name

Last Name

Suffix

Other Legal Name

Date of Birth

Date of Death

SSN

Confirm SSN

Last Address

Last Address 2

Last City

Last Zip/Postal Code

Last Country

Last State / Province

Previous Address

Previous Address 2

Previous City

Previous Zip/Postal Code

Previous Country

Previous State / Province

I certify that I have made a diligent search of the deceased person's records and property, including bank statements and safety deposit boxes, and have asked family members to identify all life policies and/or annuity contracts that I have reason to believe covered the life of the deceased person named above. I understand that life/annuity insurance companies will ONLY respond directly to the actual beneficiary if a policy is located.

I further understand that the role of DIFS is to provide the completed form to all Michigan authorized life and annuity companies. I also understand that a company may require additional information from a beneficiary if a policy is located.

For questions or assistance, contact us at 877-999-6442 (Toll-Free) or 517-284-8800.

93-964

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