Individual Annuity Claim INSTRUCTIONS This form should be completed in full detail by the named beneficiary claimant before a witness who should sign the form. If there is more than one beneficiary, each one should complete a separate form. If the beneficiary is the Estate of the Insured, the claim form should be completed by the Executor or Administrator of the Estate and must be submitted with the properly certified letters of administration. Where a beneficiary signature is required, it shall be understood that the individual signing is signing in his or her capacity as the Executor or Administrator of the Estate. If the beneficiary is a Trust or other entity, this form should be completed by the Trustee/Authorized Individual and Section 8 at the back of the claim form must be completed. Where a beneficiary signature is required, it shall be understood that the individual signing is signing in his or her capacity as the Trustee/Authorized Individual. If the beneficiary is a minor, the form must be completed by his or her legal appointed guardian and must be submitted with certified letters of guardianship. Where a beneficiary signature is required, it shall be understood that the individual signing is signing in his or her capacity as the Guardian of the minor beneficiary. In the event no guardian is to be appointed, contact the Company for further instructions. If a Power of Attorney (POA) is acting for the beneficiary, where beneficiary signature is required, it shall be understood that the individual signing is signing in his or her capacity as POA. A complete, current copy of the power of attorney document must be submitted with this form. If the beneficiary’s name has changed, a copy of a marriage certificate, divorce decree, or other legal documentation should be submitted with the completed form. Annuity death benefit elections have tax consequences. An election cannot be changed once processed. We strongly recommend you consult your tax advisor before selecting an option below. PLEASE REMEMBER TO INCLUDE THE FOLLOWING Enclose Certified Death Certificate – A certified death certificate with cause of death for the insured should be provided. Enclose Contract – Unless you have elected to continue the contract as owner, the annuity contract or contracts should be included with the claim papers. Enclose Proof of Age – If Option 4 (Payments Over Your Lifetime) is elected, please enclose proof of age with your completed Claim Form. Proof of age includes a copy of your birth certificate, driver’s license, passport, or other government issued I.D. Annuity Claim Package For your convenience this package is fillable and can be downloaded to your PC, then completed, printed, and signed. DOWNLOAD If you have any questions, please contact us. Our release of forms does not constitute our acceptance of liability. All claims are subject to a claim review, including verification of death, policy validity, and beneficiary status. It may be necessary for us to request additional information from you or a third party to properly evaluate your claim. This could result in a delay in the processing of the claim. Looking for one of our member companies? Contact Us