575 D Onofrio Drive, Suite 100, Madison, WI (877)

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1 575 D Onofrio Drive, Suite 100, Madison, WI (877) Life Claim Form Please print in black ink; do not use correction fluid. 1. DECEDENT INFORMATION a. Deceased s Full Name (First, Middle, Last) Maiden b. Other Names by Which Deceased Was Known c. Deceased s Residence Address at Time of Death (Give Number, Street, City, State, Zip Code) d. Date of Birth e. Nature of Death (If other than Natural, describe circumstances and any relevant f. Date of Death documentation.) Natural Accidental Suicide Homicide 2. POLICY INFORMATION (List all policies under which You are making a claim) Policy Number & Amount of Insurance (1) $ (3) $ (2) $ (4) $ 3. CLAIMANT INFORMATION (If not an Individual, refer to Special Claimant s Instructions on Page 6) a. Claimant s Name (If Trust, also complete TRUSTEE INFORMATION section on the next page.) b. Phone Number ( ) c. Claimant s Mailing Address (Give Number, Street, City, State, Zip Code.) and Address (if any): d. Date of Birth e. Age f. Social Security or Tax ID Number g. Relationship to Deceased h. Citizenship US Other: i. Amount or Percentage Claimed PHS-LC-CFLIC (rev. 9/13) Page 1 of 8

2 4. TRUST INFORMATION Instructions: Complete this section only if the named Claimant is a Trust. Provide a copy of the entire trust, including any amendments. a. Name of Trust b. Trust s Tax Identification Number c. Date of Trust Agreement d. Amendment Dates (if any) e. Trustee Names (Use additional sheet if necessary.) (1) (2) (3) (4) (5) (6) 5. TYPE OF SETTLEMENT Lump Sum Distribution OR Scheduled Life Payments (Select One) Life Period Certain Period Certain & Life Other 6. REPRESENTATIONS AND CERTIFICATIONS INITIALS I HEREBY: (1) make claim to the proceeds, (2) declare that all answers recorded in this Life Claim Form are true and complete, and (3) agree that the Company s furnishing of this Life Claim Form and any supplemental forms is not an admission that insurance was in force on the Deceased s life nor a waiver of its rights or defenses. INITIALS OPTIONAL IF POLICY LOST OR DESTROYED: I hereby declare that said policy is lost or destroyed, and that it has not been sold, nor transferred to any other person. INITIALS OPTIONAL TRUSTEE S CERTIFICATION (If a Trust is the Claimant, all trustees named in this Life Claim Form must sign.): I hereby certify, represent and warrant that the trust agreement to which this certification and agreement is in full force and effect and that I have the authority to make this certification. I affirm that the trust named in this Life Claim Form is in full force without change, except as noted, and I am willing to serve as Trustee of that trust. 7. SUBSTITUTE FOR IRS FORM W-9 This information is being collected on this statement rather that an IRS Form W-9 and will be used for supplying information to the Internal Revenue Service (IRS). The IRS does not require Your consent to any provision of this statement other that the certifications required to avoid backup withholding. Under penalty of perjury, I certify to the following: (1) the tax ID number I have provided on this Life Claim Form is correct; (2) I am not subject to backup withholding because I meet at least one of the following: (a) I am exempt from backup withholding, (b) I have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and (3) I am a U.S. citizen or other U.S. person (as defined in the instructions for IRS Form W-9; Form W-9 instructions are available upon request or at irs.gov.). Please cross through item 2 if You have been notified by the IRS that You are subject to backup withholding. Please cross through item 3 if you are not a U.S. citizen or other U.S. person and complete and return to us the applicable W-8 form (see Special Claimant Instructions Non-Resident Aliens or Foreign Entities for additional information). PHS-LC-CFLIC (rev. 9/13) Page 2 of 8

3 8. ACKNOWLEDGEMENT AND SIGNATURES I hereby certify that the answers I have made to the foregoing questions are both complete and true to the best of my knowledge and belief. I acknowledge that I have received, read and understand the applicable fraud notice on pages 4 and 5 of this form. Claimant s Signature Capacity in Which You Are Claiming Date Claimant s Signature Capacity in Which You Are Claiming Date NOTARY SEAL (required for claims under $50,000) Subscribed and sworn to before me this day of, 20 Signature Of Notary Public: Notary Public in and for the County of, And the State Of My Commission Expires: NOTARY SEAL SIGNATURE GUARANTEE (required for claims over $50,000) Signatures must be guaranteed by a bank, savings association, credit union, member firm of a domestic stock exchange or the Financial Industry Regulatory Authority, that is an eligible guarantor institution. A notary public is not an acceptable guarantor. The guarantee must be in the form of a stamp or a typewritten or handwritten guarantee that is accompanied by a raised corporate seal. SIGNATURE GUARANTEE PHS-LC-CFLIC (rev. 9/13) Page 3 of 8

4 FOR YOUR PROTECTION THE LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof. Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete or misleading information may be prosecuted under state law. Arizona: Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. California and Texas: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denials of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Delaware: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. Idaho: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony. Indiana: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony. Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Maine: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance, is guilty of a crime and may be subject to fines and confinement in prison. Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20. New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. New Mexico: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES. New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. (NY Claimant s Signature) PHS-LC-CFLIC (rev. 9/13) Page 4 of 8

5 FOR YOUR PROTECTION THE LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM (CONTINUED) Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement, is guilty of insurance fraud. Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Oregon: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false statement may be guilty of insurance fraud. Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Puerto Rico: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. Tennessee, Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Texas: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. IN ALL OTHER STATES: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. PHS-LC-CFLIC (rev. 9/13) Page 5 of 8

6 575 D Onofrio Drive, Suite 100, Madison, WI (877) Life Claim Form Instructions Instructions for Completing the Life Claim Form These instructions will help You submit the information We will need to begin processing Your claim. Please read them and the Most Frequently Asked Questions carefully before completing this form. If You still have questions, please call Us toll-free before sending in any information. Documents Required We require these documents in order for Us to process Your claim. Without them, We cannot complete Our processing. The entire original policy. (If the original is lost, a notarized Lost Policy Affidavit must be completed.) A separate Life Claim Form for each beneficiary. An original, raised seal certified death certificate indicating the final cause of death for the insured. We do not accept faxed, ed, photocopied, or otherwise electronically duplicated death certificates. If the Claim amount is less than $50,000, two of the following; if greater than $50,000, three of the following (photocopies are acceptable): o Driver s License o Government Issued ID o Passport data page o Medicare Card o Social Security Card o Government Issued ID o Green Card o Utility Bill o Military ID card o High School or College Diploma o Birth Certificate o Gun Registration o Marriage License o Justice of the Peace ID Acceptable to US We may require other documents depending on the specific circumstances of Your claim. (See the Special Claimant Instructions below) Federal and State Tax Withholding Generally life insurance death proceeds are income-tax-free, but in certain situations such proceeds are taxable, e.g., when the policy has been transferred for value. Any interest paid on delayed death benefits is subject to federal and state taxation. We will not withhold income tax from interest unless you are subject to backup withholding. However, you are still liable for payment of any applicable federal or state income tax that may apply to Your situation. If you have questions, please consult a tax professional. We do not provide tax advice. Claimant Instructions (Additional require NON-RESIDENT ALIENS OR FOREIGN ENTITIES Complete and submit an original IRS form W-8BEN or other applicable form W-8. As a Non-Resident Alien or Foreign Entity, your taxable income is subject to 30% U.S. federal tax withholding unless you qualify for lower withholding under a tax treaty. If you are eligible to claim tax treaty benefits, your IRS form W-8 must include a US taxpayer identification number in Part I and all applicable fields in Part II must be completed. A US taxpayer identification number may be applied for by submitting a Form W-7 to the IRS. IRS forms W-8 and W-7 are available on the IRS web site at or by contacting them at TRUST Complete the Claimant Information section with the Trust s Information. Provide a TIN for the Trust for tax reporting purposes. Example of a properly completed Claimant s Name: Jane Doe Trust. Complete the Trustee Information section on the Life Claim Form. List all current Trustees. Capacity: Indicate Capacity as Sole Current Trustee or Co-Trustee as appropriate and have each current Trustee sign unless the Trust document confers on one Trustee the authority to act alone. Special Claimant Instructions ESTATE OF INSURED Complete the Claimant Information section with the estate s information. Example of a properly completed Claimant s Name: Estate of Jane Doe. Submit an original certified copy of the Letters of Administration/Testamentary or other court document appointing the estate s Personal Representative. Capacity: Indicate Capacity as Personal Representative/Administrator or Executor/Executrix. Important Note Small Estates. The estate may qualify as a small estate under the small estate statute or another similar statute of the decedent s state of residence. If the estate qualifies as a small estate, We require a copy of the properly prepared affidavit or other form required by the state. State laws vary. Please consult Your attorney or tax advisor for more information on small estates. CORPORATION Complete the Claimant Information section with the Corporation s information. Example of a properly completed Claimant s Name: ABC Corporation. PHS-LC-CFLIC (rev. 9/13) Page 6 of 8

7 Special Claimant Instructions (Cont d) Capacity: Indicate Capacity as the title by which You are authorized to act on behalf of the Corporation. PARTNERSHIP Complete the Claimant Information section with the Partnership s information. Example of a properly completed Claimant s Name: ABC Partnership. Capacity: Indicate Capacity as Managing Partner as appropriate. All Partners or a Managing Partner must sign. MINOR/CHILD Complete the Claimant Information section with the minor s information. Example of a properly completed Claimant s Name: Jane Doe, minor. Submit a copy of the court document appointing the guardian of the minor child s property/estate (not required if the beneficiary designation named a guardian to claim the funds for the minor under UTMA; however, not all states have adopted UTMA). (Reminder: the guardian of the minor s person is not necessarily the guardian of the minor s estate/property). Capacity: Indicate Capacity as Guardian of Jane Doe, minor or for the property/estate of Jane Doe, minor. Most Frequently Asked Questions Concerning the Claims Process Life Claim Form Q. Who is the Claimant? A. A claimant is the person or entity claiming death proceeds under a policy. Each beneficiary must complete a separate Life Claim Form. Q. After I complete the Life Claim Form, can I fax it to You? A. No. We require a notarized form with original signature(s) before the claim can be processed. Q. May I copy this Life Claim Form for other Claimants use? A. Yes. You may copy the form; however, We require a notarized form with original signature(s) before the claim can be processed. Q. What is an IRS Form 712? A. IRS Form 712 is a gift or estate tax form that may need to be filed with the deceased s final estate tax return. At Your request, We will provide the value of the policy as of the date of death. For more information, please contact Your attorney or tax advisor. Q. Am I subject to backup withholding? A. You may be subject to backup withholding with respect to interest paid (1) if You have been notified by the IRS that You have underreported dividends or income or (2) You fail to certify on IRS Form W-9 or a valid substitute form that You are not subject to backup withholding. For more information, please contact Your attorney or tax advisor. Q. Does the signature on the Life Claim Form need to be notarized? A. Yes. The Life Claim Form does have to be notarized, and must contain original ink signatures. Q. What is capacity? A. Capacity is the legal authority that entitles You to claim proceeds. If You are claiming on Your own behalf, You are an individual claimant and should indicate Your capacity as Individual. Do not use any other title unless You are actually claiming in that capacity. Page 7 contains instructions for making a claim in the capacity other than an Individual. Q. If I make a mistake, how do I change information on the Life Claim Form? A. Put a line through an incorrect answer and insert the correct information. DO NOT use correction fluid. The claimant must initial all corrections. Certified Death Certificate Q. Will You accept a copy or fax of the original certified death certificate? A. No. An original, raised seal certified death certificate indicating the final cause of death for the insured. We do not accept faxed, ed, photocopied, or otherwise electronically duplicated death certificates. Q. Will You accept a certified death certificate with a pending death cause? A. No. We must have a certified death certificate with a final cause of death. Q. Are there any special requirements if the Insured died in a foreign country, i.e., outside the United States or its territories? A. We require an original certified death certificate and a Death of an American Citizen Abroad document. A Death of an American Citizen Abroad document is not an acceptable substitute for an original certified death certificate. In addition, We may require a cancelled passport, a copy of airline tickets, funeral/cremation bills, remains transport information/bills, or any other information We deem necessary based on the specific circumstances of Your claim. To avoid delays, You should contact Us immediately for detailed instructions. PHS-LC-CFLIC (rev. 9/13) Page 7 of 8

8 Most Frequently Asked Questions Concerning the Claims Process (Cont d) The Original Policy Q. Will You accept a copy of the original policy? A. No. We require the complete original policy, if available. You may make a copy of the original policy for Your records. Q. What if the original policy is lost or otherwise unavailable? A. Simply complete and sign the Life Claim Form. By signing the Life Claim Form, You are declaring that all original policies and any duplicates and certificates are lost or otherwise unavailable unless sent in with the Life Claim Form. Trust Claimant Q. What claimant information for a trust do I include on the Life Claim Form? A. Indicate the name of the trust under Claimant s Name. The trust name should include the date of the trust. For Claimant s Address, indicate a trustee s address where the death proceeds should be delivered. Q. If there are multiple trustees, how many need to sign the Life Claim Form? A. Each current trustee must sign the Life Claim Form in his/her capacity as Co-Trustee unless the Trust document confers on one trustee the authority to act alone. Q. Why do We require a trust to provide a Tax Identification Number (TIN)? A. A person who is not an individual is required by Federal income tax regulations to furnish a TIN to a payor of income. Deceased Primary Beneficiary Q. If the primary beneficiary is deceased, can I send a photocopy of the certified death certificate for the deceased primary beneficiary? A. No. We require an original certified death certificate for any deceased beneficiary. Name Change of the Beneficiary Q. If the beneficiary s name has changed since the last beneficiary designation, what do I provide to validate the name change? A. If a beneficiary s name has changed because of marriage or divorce, We require an original certified copy of the marriage certificate or divorce decree. If the beneficiary s name has changed because of personal preference, We will require a certified court decree indicating the name change. Collateral Assignment Q. Why does a beneficiary have to complete a Life Claim Form when there is a collateral assignee? A. To avoid potential disagreements over the amount payable to the beneficiary and the collateral assignee. Q. Why do You require a statement from the beneficiary and collateral assignee agreeing to the amount claimed by the collateral assignee? A. To avoid potential disagreements over the amounts payable. The agreeing statements, indicating the amount that was due at the time of death of the insured, will expedite processing of Your claim. Q. If the collateral assignment has already been released, what needs to be provided? A. A release of assignment from the collateral assignee. If the assignee is a non-natural person, We will require an officer to sign the collateral assignment release. Q. If the collateral assignee is a bank of other financial institution and the name has changed, what needs to be provided? A. We require a copy of the bank resolution or merger document for each name change. You will need to contact the bank for this information. Funeral Home Assignment Q. Can the claim proceeds from the policy be assigned to a funeral home after the death of the Insured? A. Yes. All designated beneficiaries must complete an assignment of benefits form. The form must be submitted to Us prior to the payment of the claim along with a Life Claim Form for each beneficiary. Power of Attorney Q. If I am signing as the power of attorney for the claimant, what do I need to send in as proof? A. We require a legally sufficient Power of Attorney, a form of which is available from our Policyholder Services Department. If the Claimant has previously been deemed incapacitated by a court of law, in which case We will need a Power of Attorney, plus the court declaration of incapacity. You must sign the Life Claim Form and indicate Your title as Power of Attorney for the Beneficiary. Example of a proper signature: Jane Doe by John W. Doe, Attorney-in-fact under POA dated ## /## / ####. Surviving Beneficiary Designations Q. If the beneficiary designation stipulates surviving children or siblings or other similar grouping, why do You require a notarized statement from each beneficiary indicating the name of each survivor? A. To validate all applicable beneficiaries and avoid potential disagreements over payment amounts. An agreement among all survivors insures that We pay the proper amounts to the proper parties and greatly reduces the risk of legal action to restore improper or misdirected payments. PHS-LC-CFLIC (rev. 9/13) Page 8 of 8