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Affidavit and Representations Regarding Next of Kin (Preference Beneficiary Affidavit) (The Hartford) – Form LC-7086-17, page 1
Moderate · 60/100Form Complexity Index

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What this form asks for

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This form is a sworn affidavit used in a life insurance claim to identify the deceased insured’s surviving next of kin (spouse, children, parents, or estate representative) in order of preference. The affiant certifies the information under penalty of perjury and acknowledges Hartford will rely on it to determine who should receive benefit proceeds. It is important because incorrect or incomplete information can delay payment, require reimbursement of paid proceeds, and may expose the signer to civil or criminal penalties for fraud or perjury. The form also includes state-specific fraud warnings and requires notarization to validate the statement.
Fillable fields84
Pages2
Sections18
Tables and lists1
Form Complexity IndexModerate, 60/100

The AI checks your answers before you download

16 checks built for this form, so a wrong date or a missing answer is caught before anyone else sees it.

Deceased Identification Fields Present (Name + Insured ID/Claim Number or Policy Number)

Validates that the form includes the Deceased’s name and at least one unique identifier (Insured ID/Claim Number and/or Policy Number). This is required to correctly match the affidavit to the correct claim and policy record and prevent misapplied payments. If missing or incomplete, the submission should be rejected or routed to manual review for claimant outreach before any processing continues.

Affiant Full Name Provided and Not Blank

Checks that the affiant’s name in statement item 1 is completed with a non-empty, non-placeholder value (e.g., not just initials, “N/A,” or whitespace). The affidavit is a sworn statement and must clearly identify who is making the representations. If validation fails, the form should be considered incomplete and returned for correction because the statement cannot be relied upon without an identified affiant.

Jurisdiction Completeness (State and County for Affidavit Notary Block)

Ensures the 'STATE OF' and 'COUNTY OF' fields in the affidavit notarization section are completed. This establishes the legal jurisdiction where the oath was administered and is essential for enforceability and compliance. If either field is missing, the notarization is potentially defective and the submission should be flagged for correction or re-notarization.

Notarization Date Format and Completeness

Validates that the notarization date line ('this day of, 20') is fully completed with a valid day, month, and 4-digit year, and that the date is a real calendar date. Notarization without a complete date can invalidate the affidavit and create legal and audit issues. If invalid or incomplete, the form should be rejected and the claimant instructed to obtain a corrected notarization.

Notary Identification Completed (Notary Signature and Printed Name)

Checks that both the notary public signature and the notary printed name fields are present and not blank. These elements are required to identify the notary who administered the oath and to support verification if needed. If missing, the notarization cannot be authenticated and the submission should be returned for completion.

Notary Commission Expiration Date Validity

Validates that the 'My commission expires' field contains a valid date and that the commission expiration is not earlier than the notarization date. A notary must have an active commission at the time of notarization for the affidavit to be valid. If the commission is expired or the date is missing/invalid, the form should be flagged as invalid notarization and require re-notarization.

And 10 more checks
  • Affiant Signature and Signature Date Present (Important Notice Page)
  • Next-of-Kin Section Exclusivity and Hierarchy Consistency
  • Spouse Section Completeness When Spouse Listed
  • Children Entries Completeness and 'List All Children' Enforcement
  • Parents Section Completeness and Deceased Parent Details
  • Executor/Administrator Section Requires Estate Tax ID and Contact Details
  • SSN Format Validation for All Listed Individuals
  • Date of Birth and Date of Death Format and Plausibility Checks
  • Telephone Number Format Validation (Including Area Code)
  • Address Completeness for Each Listed Next-of-Kin

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How to Fill Out LC-7086-17 Online for Free in 2026

What the AI walks you through.

  1. Enter the deceased insured’s identifying information (name, insured ID/claim number, and policy number) and the state/county where the affidavit is executed.
  2. Provide the affiant’s name and confirm the statements acknowledging the affidavit is based on personal knowledge and will be relied upon for payment of benefits.
  3. Complete the next-of-kin section in order: list the surviving spouse (if any) with full contact details, date of birth, Social Security number, and phone number.
  4. If there is no surviving spouse, list all surviving children (including adults) with their addresses, dates of birth, Social Security numbers, and phone numbers; if none, list surviving parent(s) and include deceased parent name/date of death if applicable.
  5. If there is no spouse, child, or parent, provide the executor/administrator information and include estate tax ID number; attach probated estate papers if available.
  6. Review the Important Notice/fraud statement applicable to the affiant’s state of residence, then sign and date the form where indicated.
  7. Complete notarization: sign in the presence of a notary, have the notary complete the venue/date, notary name, commission information, and apply the notary seal as required.

Common Mistakes in Completing LC-7086-17

The ones the AI is built to catch.

Leaving the Deceased identifiers blank or mismatched (Insured ID/Claim Number/Policy Number)
People often skip these fields because they don’t have the paperwork handy or assume the insurer can “look it up” by name alone. Missing or incorrect identifiers can delay processing, cause the affidavit to be associated with the wrong claim, or trigger follow-up requests. Avoid this by copying the Insured ID/Claim Number and Policy Number exactly as shown on the claim correspondence or policy documents, and double-checking for transposed digits.
Not completing the venue and notarization section correctly (State/County, date, notary details)
A frequent error is filling out the affidavit but leaving the STATE/COUNTY (venue), the “day of ___, 20__” line, or the notary’s printed name/commission expiration incomplete. If the notarization block is incomplete or signed outside the notary’s presence, the affidavit may be rejected as invalid and must be redone. To avoid this, do not sign until you are in front of the notary, and confirm the notary completes every notary field (including state, commission expiration, and stamp/seal if required).
Signing in the wrong place or using inconsistent signatures
This form has multiple signature contexts (affiant signature for the sworn statement and a signature/date on the Important Notice page). People sometimes sign only one page, sign on the notary line, or use a signature that doesn’t match their ID used for notarization. This can lead to notarization refusal, re-execution requests, or delays in benefit payment. Avoid it by signing only where the form instructs, ensuring the affiant signs as the person making the statement, and using the same legal signature as on the identification presented to the notary.
Listing next of kin in the wrong priority order (spouse vs. children vs. parents vs. executor)
Applicants commonly misunderstand the hierarchy and fill in multiple sections even when a higher-priority category exists (e.g., listing parents or an executor even though there is a surviving spouse or child). This creates conflicts and can require additional documentation or legal review before proceeds are paid. Avoid this by following the form’s logic: complete the spouse section if a spouse survives; only complete the children section if there is no surviving spouse; only complete parents if no spouse or children; only list an executor/administrator if no spouse, children, or parents.
Failing to list all children (including adults, estranged children, or legally adopted children)
The form explicitly requires listing ALL children “even if over the age of majority,” but people often omit adult children, children from prior relationships, or legally adopted children due to oversight or family dynamics. Omissions can be treated as a material inaccuracy, potentially exposing the affiant to repayment obligations and delaying payment while the insurer investigates. Avoid this by making a complete list of all natural and legally adopted children, regardless of age, relationship status, or dependency.
Providing incomplete contact details for next of kin (missing address/phone)
Many submissions include names but leave addresses or telephone numbers blank, especially when the affiant doesn’t have current contact information. Missing contact details can prevent the insurer from verifying beneficiaries or issuing payments, resulting in follow-up requests and delays. Avoid this by providing the most current mailing address and phone number available, and if unknown, attach an explanation and any partial information (city/state, last known address) rather than leaving fields empty.
Entering incorrect or improperly formatted dates of birth and dates of death
Dates are often entered in inconsistent formats (e.g., 1/2/24 vs. 02-01-2024) or with transposed month/day, especially when multiple family members are listed. Incorrect dates can cause identity verification failures, mismatches with records, and additional documentation requests. Avoid this by using a consistent format (MM/DD/YYYY unless otherwise instructed) and verifying each date against official documents (birth certificate, death certificate, or government ID).
Missing, incorrect, or improperly handled Social Security Numbers
People sometimes leave SSNs blank, enter partial numbers, swap digits, or provide a Tax ID where an SSN is requested (or vice versa). Incorrect SSNs can delay identity verification and may require resubmission, while unnecessary inclusion can raise privacy concerns if the form is sent insecurely. Avoid this by entering the correct SSN for each person where requested, double-checking digits, and using the Estate Tax ID only in the executor/administrator section where it is specifically requested.
Not indicating a deceased parent’s information when completing the parent section
When listing surviving parents, people often forget to complete the “IF ONE PARENT IS DECEASED, PLEASE INDICATE NAME” and “DATE OF DEATH” lines. This omission can create ambiguity about whether one or both parents survive, which affects next-of-kin determination and can trigger additional proof requests. Avoid this by clearly stating the deceased parent’s full name and date of death, and ensuring the surviving parent’s details are fully completed.
Executor/Administrator section completed without required estate documentation or with wrong tax identifier
Applicants frequently list an executor/administrator without attaching probated estate papers (when available) or they provide a personal SSN instead of the estate’s Tax ID number. This can lead to payment holds because the insurer may need proof of legal authority and correct tax reporting information. Avoid this by attaching letters testamentary/letters of administration or other probate documents if available, and confirming whether the number requested is the estate EIN/Tax ID (not the executor’s SSN).
Skipping the Important Notice acknowledgment (state-specific fraud notice) and signature/date on page 2
Because the fraud notice is lengthy and state-specific, people often overlook the instruction to read the applicable statement and sign/date at the bottom of page 2. Missing this signature/date can result in an incomplete submission and a request to re-sign, delaying claim processing. Avoid this by signing and dating page 2 where indicated, and ensuring the signature matches the affiant’s signature used for the affidavit.

Frequently Asked Questions About LC-7086-17

 

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How complex is LC-7086-17 to fill out?
LC-7086-17 has a Form Complexity Index of 60 out of 100, in the moderate tier: 84 fillable fields across 2 pages. Instafill.ai's AI fills it in under a minute, with every field there for you to review before you download.
What is the “Affidavit and Representations Regarding Next of Kin (Preference Beneficiary Affidavit)” used for?
This form is used to identify the deceased insured’s surviving next of kin so The Hartford can determine who should receive life insurance benefit proceeds when needed. The Hartford relies on the information in this sworn statement to process payment.
Who should complete and sign this affidavit?
The person with personal knowledge of the deceased’s family situation (the “Affiant”) should complete and sign it. The Affiant must be willing to swear under penalty of perjury that the information provided is true and correct.
Does this form have to be notarized?
Yes. The form includes a notarization section that must be completed by a Notary Public, including the date, state, notary signature/printed name, and commission expiration.
What identifying information do I need to provide at the top of the form?
You should provide the Name of Deceased, Insured ID/Claim Number, and Policy Number. If you don’t have one of these numbers, provide what you have and contact The Hartford for help locating the missing information.
What does the Affiant certify by signing this form?
By signing, the Affiant declares under penalty of perjury that the statements are true and correct. The Affiant also agrees to reimburse The Hartford if benefits are paid based on inaccurate information, even if the error was unintentional.
Which relatives must be listed as “next of kin” on this form?
The form asks you to list next of kin in order: surviving spouse (widow/widower), then children (natural or legally adopted), then parents, and if none of those exist, the executor/administrator of the estate. You should complete the section that matches the deceased’s situation.
Do I need to list all children, even if they are adults or not financially dependent?
Yes. The form specifically instructs you to list all children, even if they are over the age of majority, as long as they are natural or legally adopted children of the deceased.
What information is required for each next-of-kin person listed?
For each person, the form requests name, address, date of birth, Social Security number, and telephone number. Provide as much complete and accurate information as possible to avoid delays.
What if the deceased had no spouse and no children?
If there is no surviving spouse or children, you should complete the “Father and/or Mother” section and list the surviving parent(s). If one parent is deceased, you must indicate that parent’s name and date of death.
When do I fill out the Executor or Administrator section, and what documents are needed?
Complete that section only if the deceased left no surviving spouse, children, or parents. The form asks you to provide probated estate papers if available, along with the executor/administrator’s name, estate tax ID number, address, and phone number.
What if I don’t know a next of kin’s Social Security number or phone number?
Provide the information you do know and try to obtain the missing details before submission, since incomplete information can slow processing. If you cannot obtain it, note that it is unknown and contact The Hartford for guidance on acceptable alternatives.
What is the “Important Notice” about fraud, and do I have to sign it?
The “Important Notice” explains state-specific fraud warnings and penalties for providing false or misleading information. You must sign and date at the bottom of that page to confirm the statements are true and complete to the best of your knowledge and belief.
How do I know which state fraud notice applies to me?
Use the statement that matches your state of residence as listed on the form (some states have specific wording, while others fall under the “all states except” category). If you are unsure, use your current legal residence state and ask The Hartford if clarification is needed.
How long does processing take after I submit the notarized affidavit?
The form itself does not list a specific processing time, and timing can vary based on completeness and any required follow-up. Submitting a fully completed, signed, and notarized form (and estate papers if applicable) helps reduce delays.
Where do I submit this completed form?
Submission instructions are not shown on the provided pages. You should follow the claim packet directions or contact The Hartford claims team to confirm the correct mailing address, fax number, or online upload option for your claim.
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