Americo Form – Fill Out and Use This PDF

P. O. Box 410288

Kansas City, MO 64141-0288 800-752-1387

Dear Sir or Madam:

We are sorry to learn about your recent loss and extend our condolences. To begin processing the claim for benefits under this policy, we need the following documentation and forms completed and returned by the beneficiary.

CLAIMANT’S STATEMENT: Note: Must be signed by the beneficiary and witnessed by a disinterested party or payment may be delayed. The Claimant’s Statement does not need to be notarized.

CERTIFIED COPY OF THE DEATH CERTIFICATE: for the insured that identifies both cause and

manner of death. Note: We cannot accept a photocopied death certificate for the insured person. A “certified” death certificate will have a “raised/embossed” or colored seal on the front. Generally, only one copy of the certified death certificate is necessary, even in the case of multiple beneficiaries. If any primary beneficiary pre-deceased the insured, we will require a photocopy of that beneficiary’s death certificate. Death certificates become part of the file and cannot be returned.

ORIGINAL INSURANCE POLICY: Note: Please be sure to mark the Claimant’s Statement where indicated if the policy is lost. If the claim is on a rider and the policy still provides coverage on additional individuals do NOT return the original policy. Please provide only a photocopy of the Policy Data Page and applicable insurance rider.

COPY OF THE OBITUARY: (if available).

BENEFICIARY NAME CHANGE: Note: If the beneficiary’s name changed after the owner designated the beneficiary, please return documentation of the name change (Marriage Certificate, Divorce Decree, etc.)

Please mail these documents to Americo Life, Attn: Claims, at one of the following addresses:

Other than the original policy and Certified Death Certificate, faxed documents, including the Claimant’s Statement, are generally acceptable and may be faxed to (800)-395-9238 or emailed to forms@americo.com.

To assist with filing your claim, please read the Instructions to the Claimant Statement. If you have any additional questions or need further assistance, please contact our office at (800) 231-0801.

Sincerely,

Claims Department

Americo Financial Life and Annuity Insurance Co. (formerly The College Life Insurance Company of America) • Great Southern Life Insurance Co. • The Ohio State Life Insurance Co. • United Fidelity Life Insurance Co. • National Farmers Union Life Insurance Co. • Financial Assurance Life Insurance Co. • Investors Life Insurance Company of North America • Companies Administered by the Americo Group of Companies: Protective Life Ins. Co. (formerly Ohio Life Ins.) • Berkley Life and Health Ins. Co. (formerly Investors Guaranty Life)

•First Health Life & Health Insurance Co. (formerly Loyalty Life Ins. Co.) • Fremont Life Ins. Co. • Renaissance Life & Health Insurance Company of America (formerly Central National Life of Omaha) • Pavonia Life Insurance Co. of NY (formerly First Central National Life of New York) • Conseco Life Insurance Co. (formerly Massachusetts General Life Insurance Co.) • Life Insurance Company of North America • Athene Annuity and Life Company (formerly American Investors Life)

INSTRUCTIONS & CLAIMANT’S STATEMENT

CLAIMANT’S STATEMENT must be completed by the person(s) or entity to whom the insurance is payable. If there is more than one beneficiary, you may make copies of this form as needed.

Please review the instructions below for the applicable beneficiary type before completing the Claimant’s Statement.

•Individual beneficiary who is the age of majority or older: The statement must be completed and signed by such beneficiary and witnessed.

•Trust: The statement must be completed by the Trustee(s) and include the full name of the trust along with the Trust documents.

•Estate: The statement must be completed by the Executor(s) or Administrator(s), and submitted with the Letters issued by the Court appointing that individual.

•Company or Corporation: The statement must be signed by two officers and include each officer’s title.

•Minor: The statement may be completed by the Court appointed Guardian of the minor’s Estate and submitted with a copy of the Court issued appointment or in accordance with other applicable state law. Proceeds may also be held with the Company at interest until the minor reaches the age of majority, which varies by state.

If a policy has been collaterally assigned by the owner prior to the death of the decedent, a Statement of Interest is also required. This document provides a statement of the assignee’s interest and may be obtained by contacting our office.

IRS Certification:

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 to me), 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. citizen or other U.S. person (that is, an individual who is a U.S. citizen or U.S. resident alien, a partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, an estate [other than a foreign estate], or a domestic trust [as defined in Regulations section 301.7701-7]).

Certification instructions: 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. Your signature at the bottom of this form certifies that you have read and attest to the information provided.

FRAUD NOTICE

Several states require that a notice be provided to each claimant to protect against Fraud. The undersigned acknowledge the Fraud Notice document has been received, read and is incorporated by reference if the State in which the undersigned resides in is listed on that notice. 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 denial of insurance benefits.

SIGNATURE

The undersigned agrees that this Claimant’s Statement constitutes their claim for proceeds, if any, under each of the above- listed policies as such were contractually in force at the time of the Deceased’s death and that furnishing of this Statement does not waive any contract provisions.

Witness Address and Phone Number [MUST BE SIGNED BY A WITNESS]

14-040-4

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 and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and 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 NH R.S.A Section 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 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.

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.

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 with the penalty of a fine of not less than five thousand ($5,000) dollars and not more than ten thousand ($10,000) dollars, 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, Washington, 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.

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.

Version 03/2017