Report the death of a member

Deceased Member Information
Full Name of Deceased*

First NameLast Name
Royal Neighbors Certificate Number
Additional Certificates (if any):
Date of Birth

MonthDayYear
Date
Date of Death*

MonthDayYear
Date
Cause of Death

NaturalAccidentalOther
Location of Death

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Your Information
Full Name*

First NameLast Name
Phone Number
E-mail
example@example.com
Your Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Relationship
Funeral Home
Name of funeral home
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number
Beneficiary Information
Please provide the following information for each Beneficiary: Full Name, Phone Number & Address
Insurance with a Difference℠
Royal Neighbors of America® is a nonprofit insurance organization that blends life insurance coverage with the joy of giving back. We call this Insurance with a Difference℠.

As part of this promise, we provide all beneficiaries access to Empathy, a complimentary service providing personalized and immediate support for the practical tasks and emotional heartache experienced after loss. This service is provided at no charge to the beneficiary.
By checking this box, I affirm that I am a named beneficiary to the Royal Neighbors certificate identified above and consent to have my contact information shared with Royal Neighbors' third-party partner, Empathy.
To learn more about Empathy, click here.
Additional Information
Please enter any additional comments
J0003 Rev. 3-2024
Should be Empty:

Deceased Member Information

Your Information

Funeral Home

Beneficiary Information

Insurance with a Difference℠

Additional Information