HomeMy WebLinkAboutContracts & Agreements_182A-2014_CCv0001.pdf ATTACHMENT "B"
National Life Insurance Company'
AiNational Life Life Insurance Company of the Southwest'"
��Groupo Claimant's Statement
Claim is made by the undersigned for proceeds of the policies indicated in accdxdance with the provisions thereof.
Policy/Ceriificate Numbers): 54997OX
Decedent information:
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ae of Deceased: Birth pate of Deceased:(maVOyyT�y)
Cause of Death: Oate of Death:(mmld&yy}y)
Letraal Residence of Deceased:(C1VrbwWCounfv.s1ata1 `Place of Death: (Cfly/rowYCotdy,Sfaie)
Claimant Information:
Full Name: Bidh Data:
e n-Y'l tlrF-
Mailing Address: Phone Number,
Relationship to Deceased.,
k CA q2x" 3
Instructions:
1. A Claimant Statement is required to be completed and submitted for each beneficiary.
2 Every question should be answered fully. The company may recfi vire or obtain further information should it be deemed necessary.
3. Review Payment Options on page 2.
4. The Claimants Statement mast be signed by the person or persons legally entitled to receive the proceeds as banafictary named in the policy.
If claim is made by an Executor,Administrator,Guardian,Trust,or other legal representative,all authority derived from a court must be
established by a currant certificate of appointmenL
a. If proceeds are payable to children unnamed in tics policy,a Lawful Child Affidavit giving the names,birth dates and Sadat Security
Numbers of all the children must be completed and submitted with this claimant statement by a disinterested person having knowledge
Of the facts.
b. When proceeds are payable to a corporation,the Claimant's Statement must be signed in the name of the corporation by an authorized
officer:
c, If proceeds are payable to a Trust,the trustees should sign in capacity as trustees and not as individuals.If the trustee Is a corporation,
claim should be mace by an authorized officer and the corporate seat should be affixed.A Trust Certification form 5213 or the signature
page of the Tnist is required Indicating who is authorized to sign on behalf of the TrusL Form 5213 can be provided if requested
d The court ordered appointment of Guardian of the Property is needed for each minor child,along with the Social Security Numbers of
all minors.
e. If proceeds ars payable to an Estate,the Executor(s)should furnish a cerlyfted copy of the court appointment
5. A copy of the insured's death certificate obtained from the ptbic records and bearing an original certification of the issuing office should be
furnished which should reflect the cause and manner of death,
S If any beneficiary designated to receive proceeds at the insureds death shall have predeceased the insured,and the Company has not
already been fumished with evidence of such beneficiary's death,a copy of the death cerfifrcate should be furbished.
7. All documents relative to this claim written in a foreign language must be accompanied by a sworn translation into English.
ti. If the death certificate lists the deceased marital status as divorce and the decendent rived in one of the fisted community states of AR,CA,lO,
LA,NV,NM,TX,WA,or WI,a full copy of the divorce decree is teored.
1518(0113) National Ute Group is a bade name of National We Insurance Canpany,Monlpelier,Vr.life Insurance Company of the Page 1 of 4
Cal.No.40337 Sou0iwest(LSW),Adson,TX and their affiliates.Each cw p ny of National Life Group is solely responsible for its own
financial condition and contractual obligations.LSW is not an authorized insure in New Yak and darns not conduct insurance
business in New York.
Centralized Mailing Address:One National Life Xfe,Montpefi%Vr 05604 1 wm.NationalLiWrotp.com
Clainitant's Statement-Continued
Payment Options: Please choose one of the following options 1 to 10 beloir.Once an option is chosen,you will be unable to make a change.
Options 1 and 2 are available for Life insurance and Annuity Claims (Best available on irnmedlate annuities or annultized contracts that are
already in a payout please.)
1 Lump Sum via 5ecurePlus access Account(see enclosed brochure):
it the(a)cam proceeds are payable to an individual and(b)claim proceeds exceed$10,000 00 and(e)beneficiary resides in a state that
permits this type of settlement,the payment of proowds can be made through the SecuraPlus Access Account.This account is an interest
bearing account.
2Jump Seam via Check or Direct Deposit: if by direct deposit please remit a voided check
Options 3 and 4 are additions" Payment Options for Annuities Only:(Not available on Immediate annuities or annuLtfzed contracts that are
already in a payout phase.)
3 Spousal Continuance: If the spouse of the deceased owner is the sole beneficiary,the annuity contract may be continued in the name of the
spouse as the new arinuitantlowner,if allowedby contractual terms
A. Inherited Account:If available A non-spouse can elect to purfiase a new contract from proceeds Proceeds paid to you over your kfa
expectancy a sng the IRS RMD Dngfe Life Table
Option Is S through 10 it selected we will provide you with a projection of the paym ant amount available and appropriate forms under separate cover
5 Income for Specified Period:Proceeds paid in equal installments for a speafic number of year Upon your death any remaining payments
;vf:t be pa d to your namad beneCciary(ies)
Terra Period Se'ec€ed (Note the minimum is 5 years and no payout may extend beyond beneficiary lite expectancy)
k1cidde Selected (monthly,quarterly,semi-annual or annual)
6 Life Annuity With Period Certain:Proceeds paid in equal instal=,meats for a guaranteed number of payments,and then for as long as you are
loving Upon your death,but prior to the end of the Period Certain,your named benericiary(ies)will continue to receive the remaining payments
upon yourdsalh,uut after the Period Certain,payment cease.
Twee;Period Salected (Mote the min mum is 5 years and no payout may extend beyond beneficiary He expectancy)
,Mode Se!nled (monVy.quarterly,semi-annual or annual)
7 Income for a Specified Amount:Proceeds paid as a specified amount until the princ-pat and interest are exhausted Upon your death,your
named benaficiary(ies)will continue to receive the specified amount until the prinepal and interest are exhausted.
Specified Dollar Amount
Mode Selected -- (monthy,quarterly,serol-annual or annual)
8 Life Annuity:Proceeds paid,n e-quai installments for your lifetime.Payme9l.ceases on the'fast payment prior to death
Mode SeMoted (iaonL:`ey,quarteily+,semi-arinual orarinual)
°. Joint and Two-Thirds.Annuity:Equal payments shall.be made while two chosen individuals els era both inrng. Upon the doath of either,
two-thirds of the amount of each payment shall continue during the life of the survivor.
Mode-Selected (month'y,quarterly,sen+-annual or annual)
10 50%Survivor Annuity:Equal payments shall be mads during the life of the chosen pnmary life Upon the death of the chosen primase tire.
500%of the arount of such payment she'll continue during the life of the chosen secondary life.
Mode Se'.UM (monthly,quarterly,rami-annual or annual)
NOTE: For more information regarding the above settlement options,please contact the Claims Examiner who sent you this form.
1 For payment options 6,8,S i£10 involving a fife annuity we will r_quira pivot of f=irth(birth carnficates)or other legal forms of proof.
2 Please:ndtcate payment option selected on page 3
3. if an option is not selected,a lump sum settlement till be provided by a 5ecurePlus Access Account, if alto%ved
by the state regulatiions governing this policy/certificate. SecurePlus Access Accounts are not available in the
states of Ali, FL,KS,KY,LA,NC or Ftl.
4 For payment options 5 through 10 beneficiary mforrnation.s strongly recomimanded and a beneficiary form will be provided for you to complete
if you select one of these options,
a For Annu ty Cia<ins alt payment optlons have federal guidat.^es when payment must begin.For individual Retirement Accounts(IRA)and
Penson Type Arrangements,such as a 401(k),403(b),412(1)and other Pension Plans,payment must begin by 12131 following the year of death
For Kon-quaiif€ed money.payment must begin by one year from date of death.If payment has not begun by these time frames,all claim
proceeds must be paid out within five years from date of death
6 Other payment options may be available,Please check the copy of the dd=ccedanrs policy form.
tWt41?3) °age 2 of 4
Clalmanfs Statement-Contimad
Taxpayer Identfication Number(TIN)(Read carefully.)
You(as payee)are required bylaw to provide us(as payer)with your oumecl TiN if you are an indim&all your TIN is your social wudty nut ser,.
otherwise dis your Emp4oyar Ideritificalion Number. J you have not pfwc led us with your mTect TIN,you may be subject to penalties imposed by the
Internal Revaque Service.
In addition,interest payments that we make to you rrisy be subject to backup withholding. If interest payments are sub to backup withholding,a
payer is required to apply backup wiftdding on the payments made to you Backup withholding is root an additional tax. Rather the tax liability of
persons subjKt to backup withholding wfl be reduced by the amount of tax wjftefcf. If willoldrig results in an overpayment of taxes,a refund may
be obtained.
Now to ObUin a Tax Identification Number(TIN)
it you do noh have a TIN,you shiou d apply for one in=e-Siately To apply for the number obtallin Form SS-5,Appflcalion for a Social Security
Number Card(for mWiduals),or Form SS-4,Applitallon for Employer k6riftation Number(for businesses and all other entities),at your local
office of the Social Security Administration,or the Internal Revenue Service. CwVlete and file the appsiae fon socording to its instructions.
Payments you race Ye will be sut�ect to backup wthhddrN if
1. You do not furnish your TIN to the payer-or-
2, IRS notifies the payer that ycu ItuTtished an Incorrect TIN,-or-
3. You are notifed by IRS that you are erect to backup withholding becauise you Wed to repor,all your interest
and dividends on your tax raturn only,-or-
4. You fail to certify to thes payer that you are not subject totackup withh=olding under(3)above,-or-
6, You faillocenifyywTIN This Mies on-y to interest payments,
Taxpayer Identificabon Number Certification
Under penalties of pertury,I certify that(1)the number shown on this c4mant statement s my correct taxpayer Identification rhmft-,(2)the IRS
has never rofiW me that i am svblact to backup wthholding,or has notified me that I am no longer subject to such withholding or I am exempt
from such wilhhokkng,and(3)1 am a U S person(triclucling a U,S.resident alien). You must cross out item 2 if you have been notified by the
IRS that you are currently subject to backup vitt 4oiding because of underreporting tit sl or dividends on your tax refum
Taxpayer tdendficafion Number-for all Accounts,
ffov,MUST indicate your TIN below. I[yDu do not have a TIN,please refer to insftuctions above)
Social Security Number Ernployer identification Number
7
Notice of withholding on W ctaim proceeds for annuities.The paymenirecisived from this death claim may be subject IQ federal income tax
wihhulding4 any part of this payment is taxable,we are reqjred to withhold and report to the Internal Revenue SeNtice,'hithhotin g will only
appy to the alion of Uw payment haat�s=Iudable as nwme on your tax return
For annoifim wNch are part of e Penson Type ArTangement,iedemil willihofdrig;of 20%of this payment i's required to bewilh)eld.You may not
opt out of this reWired withholding
For annuibes eoris;iderecl,as an IRA or non-qualif ed.flade-ral withholding of 10%is required to be withheld,however,for IRA and iron-qualified
arinutles you may elect not to have federal wthholdings but it so el ted,you may be rasi=sible for payment of estimated tax and may incur
penalties under the estimated tax sales if the withholding and estimated tax payments are not suffidenlL
Withholding lastructions for IRA and Non-clualifled Arra uiU"Only., Please check ona or mare of the follawim boxes
0 1 elect to have state income lax withheld %or$
1 da no(want to have state incorne tax withheld unless state law so requires.
I do not want federal income tax withheld.
To the best of my knowledge,the undersigned certifies that no procesdings either volunmry or in4untary,under the United States Bankruptcy law
were pending against IN do-ceased at the time of the decederifs death and none are now peng against IN undersigned. I also agree to fully
indemnify and reimburse ll ie Company for any and all loss,expense or damage it may sustain from any claim resulting from the Company having
paid the contract(s)without securing surrender of the original contract(s)or any pieviously issued duplicatelcerMcatim-
NOTICE. BEFORE SIGNING BELOW READ THE IMPORTANT FRAUD WARNING NOTICE ON PAGE t
The laf&nal Revenue Service does not requwa your conseni to any provision of this da cent obinz than the required to avoid backup
wilhhold ing. The followfng informaYon is foir the Clisimant for the above SSN or EIN:
Claimarics S Date fmnWcVyM) Payment Option Selected,
11t,
Sam Ir v CIL-rk
Page3afil
Claimant's statement-Continued
Please read the following notices applicable to the state of residence of the deceased and each claimant:
FRAUD WARNING:Any person who knowingly and intentionally provides materially false,incomplete,or misleading
information(including concealing material information)from an insurance company for the purpose of deceiving or
defrauding the insurance company commits a fraudulent insurance act,which is a crime, and may be subject to the
denial of insurance benefits,as well as subject to Fines and/or imprisonment. In Delaware, Florida, Idaho,Indiana,
Oklahoma and certain other states,this crime may be a felony.
The laws of the following states and the Distdct of Columbia require the following statements:
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.
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.
CALIFORNIA: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 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.
DISTRICT OF COLUMBIA:Any person who knowingly presents a false or fraudulent claim for payment of a toss 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.
KENTUCKY AND PENNSYLVANIA,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 and
subjects such person to criminal and civil penalties.
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.
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 YORK:Any person who knowingly and with intent to defraud any insurance company or any 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 be subject to a civil penalty not to exceed S5,000 and the stated value of the claim for each such violation.
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