Verification Request Form Great Southern Life verification request form for use by funding companies or funeral homes. "*" indicates required fields Δ Assignment Company/ Funeral Home Name**Requester Name*Assignment Company/ Funeral Home Phone Number*Requester Email* Policy Number*Deceased Name*Deceased Date of Birth* MM slash DD slash YYYY Assignment Number*Beneficiary Name*Disclaimer* By requesting and receiving policy information, you accept and agree to be bound by of the following terms:Great Southern Life Insurance Company (Great Southern Life) provides policy information as a courtesy. You understand and acknowledge that such information does not constitute a representation or warranty as to the policy cash value, death benefit (including but not limited to any outstanding loan amounts or premiums due), identity of beneficiaries, contestability, or any other policy status. No business relationship exists between you and Great Southern Life, and you agree you are using the information provided at your own risk. You understand all policy information provided is not guaranteed, and therefore cannot be the basis for any claim of determinantal reliance or estoppel. Your organization waives all rights to any cause of action against Great Southern Life based on your use of or reliance on the policy information provided. You further agree to indemnify and hold harmless Great Southern Life, including its employees, agents, parents, subsidiaries, and assigns, from any claims, liabilities, damages, and expenses (including, without limitation, reasonable attorneys’ fees) arising from your use of this information.Upload Assignment and Verification Request Drop files here or Select files Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 15 MB, Max. files: 5. An assignment form, signed by the beneficiary or beneficiaries, is required. Please note that this is for verification only. If you are submitting claimant statements, a death certificate, or other documents, upload them on our claims page: Greatsouthern.com/claims or send to forms@greatsouthern.com
