Life Insurance Claimant s Statement Policy Policy number(s) Information Name of Deceased Other names by which the deceased may have been known 55 No. 300 West, Suite 375 Salt Lake City, Utah 84101 (801) 933-1100 (800) 233-7979 www.beneficialfinancialgroup.com (Such as maiden name, hyphenated name, nickname, derivative form of first and/or middle name or an alias) Date of Birth Date of death Social Security Number Cause of Death Marital Status: Single Married Widow/Widower Separated Divorced Name of Spouse Beneficiary Information One claim form per Beneficiary, please print clearly or type Beneficiary Name Address City, State, ZIP Social Security Number Date of Birth Male Female / Your Relationship to Decedent Phone Number: Day ( ) Alternate ( ) Marital Status: Single Married Widow/Widower Separated Divorced Trust/Estate Tax ID Date of Trust (If Applicable) Are you a citizen of the United States of America? Yes No If No, list country and attach a copy of the front and back of your Permanent Resident Visa (Green Card). Country of Birth (if other than the United States): Beneficiary name has changed: Please complete only if current name is different from that listed on policy records. The beneficiary new name is: New Full Name (please print) Previous Full Name (please print) Reason for change: Marriage Divorce Adoption Other (Explain) Please provide a copy of supporting documentation for name change; i.e., marriage certificate, adoption certificate, social security card, divorce decree, naturalization verification, court order, or other documentation determined acceptable by Beneficial Life Insurance Company. Please call our Benefits Department at 1-800-283-8931 for assistance. LCL01 03/14 Page 1 of 6
When did Deceased first give indication of last illness? If the policy is less than two years old, list the names and addresses of all physicians who attended the deceased and all hospitals or institutions where treated during the last illness (attach additional page if necessary include policy number). Name Address Date Disease or Condition Settlement Options Cash Settlement* Other * For personal beneficiaries receiving $5,000 or more, the cash settlement option is the Beneficial Legacy Account. The Beneficial Legacy Account is an interest-bearing draft account in your name. You will receive a checkbook, and may immediately access all or a portion of the funds by writing a check against the account. **Legacy Accounts are not available to residents of Maryland or New Jersey. If you have questions about the Beneficial Legacy Account, or if you would like more information about other settlement options (e.g., installment or life income options), please call us at 1-800-283-8931. Transfer all proceeds to an existing Beneficial contract: Existing contract # is required. These options are available to all individual beneficiaries. Beneficial Financial Group Professional Agent Name: Agent No: Address: Phone #: Fax #: Would you like to deliver the proceeds? Yes No Special Handling Instructions: LCL01 03/14 Page 2 of 6
Substitute W-9 Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued), and 2. I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (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. person (including U.S. resident alien). Check this box if you have been notified by the Internal Revenue Service that you are subject to backup withholding on interest and dividends. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. The Internal Revenue Service does not require your consent to any provisions of this document other than the certification required to avoid backup withholding. Authorization and Signature The undersigned beneficiary hereby make(s) claim for life proceeds. The furnishing of this form, or any other forms supplemental to it, is not an admission that there was a life contract in force, nor a waiver of any rights or defenses of the Company. I/We certify, under penalty of perjury, that the information above is true, correct and complete to the best of my/our knowledge, and I/We have read the fraud notice and required statements associated with this statement. (If signing for another entity other than yourself include your title, see authorization and signature instructions on pages 4-6) Beneficial accepts these and all other ancillary documents solely for own use in processing policies and claims. Our acceptance of such documents does not constitute acceptance of any related fiduciary duty, any duty to store or preserve such records, or any duty to return or produce copies or originals of such records. The death benefit option chosen is irrevocable and may not be changed once the claim has been processed. Beneficiary Signature Sign as you sign checks Date Notice of Anti-Money Laundering Procedures Beneficial Life Insurance Company complies with all applicable state and federal anti-money laundering laws. Like other financial institutions, we are required to report suspicious activities, large cash transactions, and persons or entities appearing on certain government lists for prohibited transactions. Government agencies may require disclosure of information, restrict release of funds, or deny any transaction suspected as illegal. Beneficial Life Insurance Company is not responsible for any resulting inconvenience, loss, or damage. LCL01 03/14 Page 3 of 6
Signature Instructions Estate: If the beneficiary is an estate, a certified copy of the court document appointing a personal representative, executor or administrator must be provided. The executor or personal representative will need to complete the claim form. If we do not have the estate s tax identification number we will use the decedents. Trust: Revocable or Irrevocable Trust: If the proceeds of this contract are payable to a trust, we will also need our Trustee Certification of Trust form completed. If signing as a trustee, you certify that the trust is in full force and effect and has not been altered, modified or revoked. Guardian/Conservator: If the beneficiary of this policy has had a guardian or conservator appointed by a court, we will need a certified copy of the court order appointing the guardian or conservator. This Claimant s Statement should be completed by the guardian or conservator. They will need to use the Social Security number of the beneficiary of this policy. We will not be able to accept the form if the guardian or conservator s Social Security number is used. By signing as a guardian or conservator, you certify that you are acting on behalf of the beneficiary, are authorized to do so and that the guardianship or conservatorship is still in effect and have not been revoked. Corporation: If the beneficiary is a corporation, the Claimant s Statement needs to be completed by an authorized officer of the corporation. They will need to include corporation s tax identification number and a copy of their current corporate resolution. They will need to sign the form stating his/her title. Partnership: If the beneficiary is a partnership, the Claimant s Statement needs to be completed and signed on behalf of the partnership by all of the partner(s). They will need to include the partnership s tax identification number, a copy of the Partnership Agreement pages showing the names of the partnership, its partners and signature pages. Power of Attorney: If an attorney-in-fact under a Power of Attorney is completing the Claimant s Statement for the beneficiary, we will need a copy of the Power of Attorney. If the Power of Attorney document is more than two years old, we will need a completed Attorney-in-Fact Certification of Power of Attorney Form. The Social Security number of the person who granted the Power of Attorney must be used. The attorney-in-fact s Social Security number may not be used. If a tax identification number is not provided, a mandatory 31% tax withholding will be assessed. The beneficiary assumes full responsibility for electing a settlement option. Instructions for Completing Proof of Death Proof of death ordinarily consists of: 1. Claimant s Statement (One claim form per Beneficiary, entire six page document must be returned) 2. Certified copy of the death certificate (One per claim, all Death Certificates are returned after claim is paid) 3. Trustee Certification of Trust form (if trust is the listed beneficiary). 4. Policy (If policy is lost, misplaced, or you wish to retain contract please make notation on claim form) The Company may require other information in certain circumstances. Some of these other requirements are given below: If the primary or first beneficiary is deceased, we will need evidence of this death. If there is more than one beneficiary, please complete a separate six page form for each beneficiary, providing us with their name, address, social security number and signature. If an estate, executor or personal representative is the beneficiary, a certificate of the appointment and qualification of the executor or personal representative by the court must be submitted to the Company. If a minor is a beneficiary and no custodian has been named to receive the beneficiary(s) share, a guardian or conservator must be appointed by court proceedings and a certificate of the appointment must be submitted to the Company. If no guardian is appointed, the funds will be held at simple interest until the minor becomes of legal age and requests payment. If proceeds are payable to a group, such as "children", a statement must be submitted to the Company giving the names, dates of birth and social security number for each. If any have died, proof of death for each deceased child must be submitted. If the proceeds of the policy have been assigned as collateral security for a loan, the assignee must furnish a written statement of the amount due and the beneficiary should verify in writing the correctness of the amount. LCL01 03/14 Page 4 of 6
Fraud Notice Any person who knowingly, and with intent to defraud any insurance company or other person, files an application of 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. These states require the following fraud warnings: 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: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. Arkansas: 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. California: (For your protection, California law requires this to appear). 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, denial 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 policy holder or beneficiary for the purpose of defrauding or attempting to defraud the policy holder or beneficiary 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. Hawaii: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. Idaho: Any person who knowingly and with intent to defraud, or deceive any insurer, 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. LCL01 03/14 Page 5 of 6
Fraud Notice (continued) Louisiana: 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. 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. 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 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. 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: A person who willfully and with intent to defraud or knowing that he is facilitating a fraud against an insurer and submits an application or claim containing materially false information or a deceptive statement may be guilty of insurance fraud and may be subject to criminal penalties. 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. Tennessee: It is a crime to knowingly provide false 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. Virginia: 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. 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. Washington, D.C. (District of Columbia): WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by an applicant. LCL01 03/14 Page 6 of 6