Welcome to The Secure Life Group LLC

1-708-359-2613
info@thesecurelifegroup.com

THE SECURE LIFE GROUP, LLC

SUPPLEMENTAL UNEMPLOYMENT INSURANCE CLAIM APPLICATION

FILING INSTRUCTIONS

Complete this application and include any applicable attachment(s). Print or type the information. Use blue or black ink only.

Answer all questions on each page. Review your application thoroughly for completeness. An incomplete application may delay or prevent the filing of your claim, or cause benefits to be denied. If you are required by the insurer to verify any of the information you provide while filing a claim, you will receive additional forms by mail and will be asked to provide additional information and/or documentation.

APPLICATION QUESTIONS

The answers you give to the questions on this application must be true and correct. You may be denied benefits if you make a false statement or withhold information.

1. What is your full name?



2. Is this the name that appears on your Social Security card?

a) If no, provide the name that appears on your Social Security card.



3. List any other names you have used.
4. What is your birth date?



5. What is your gender?
6. What is your Social Security number as given to you by the Social Security Administration?



6.a) List any other Social Security numbers you have used?











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