Fillable Form C-5082 - Proofs Of Death-Claimant'S Statement (Page 2 of 3) in pdf

GENERAL INSTRUCTIONS

1. Claimant's Statement. This statement must be completed by the beneficiary. If there is more than one beneficiary, each must

complete a separate statement.

2. Death Certificate. A Certified copy of the death certificate is to be furnished with this form.

3. Newspaper Account. When available, a newspaper account of the death should be submitted.

4. Policy. The policy should be sent with this Statement. Explain if not enclosed.

SPECIAL INSTRUCTIONS

Estate Beneficiary. The Statement must be completed by the Executor or Administrator, and a certified copy of appointment must be

furnished.

Minor Beneficiary. The Statement is to be completed by the legally appointed guardian of the Estate of the minor and an official certifi-

cate of the guardian's appointment must be furnished.

Predeceased Beneficiary. When a beneficiary has predeceased the insured, a certified copy of the death certificate is to be

furnished.

Class Beneficiaries. (Example: "Children of the Insured") An affidavit showing the names and dates of birth of each must be submitted,

or submit a copy of an Obituary or copy of Will listing all persons in the designated class.

Assignee. The Statement is to be completed by the assignee. If the assignment is no longer effective, a release of assignment

from the assignee should be submitted. If collaterally assigned, the statement should be completed by both the beneficiary and

assignee and the amount claimed by the assignee indicated on the statement.

Guidelines for Determining the Proper Identification Number to Give the Payer.—

Social Security numbers have nine digits separated by two hyphens: i.e., 000-

00-0000. Employer identification numbers have nine digits separated by only one

hyphen: I.E., 00-0000000. The table below will help you determine the number to

give the payer.

Give the

Give the TAX

For this type of account:

SOCIAL SECURITY

For this type of Account

IDENTIFICATION

number of—

The individual

1. An individual's account

8. Sole proprietorship account

The owner

The actual owner of the ac-

2. Two or more individuals

Legal entity (Do not furnish

9. A valid trust, estate, or pension trust

count or, if combined funds,

(joint account)

the identifying number of the

any one of the individuals

personal representative or

trustee unless the legal entity

The actual owner of the ac-

3. Husband and wife

itself is not designated in the

count or, if joint funds, either

(joint account)

account title.)

person

10. Corporate account

The corporation

4. Custodian account of a minor

The Minor

(Uniform Gift to Minors Act)

The organization

11. Religious, charitable, or educational

5. Adult and minor (joint account)

The adult or, if the minor

organization account

is the only contributor, the

minor

The partnership

12. Partnership account held in the name

of the business

6. Account in the name of guardian or

The ward, minor, or

committee for a designated ward,

incompetent person

13. Association, club, or other tax-exempt

The organization

minor, or incompetent person

organization

7. a. The usual revocable savings

The grantor-trustee

14. A broker or registered nominee

The broker or nominee

trust account

(grantor is also trustee)

15. Account in the Department of Agri-

The public entity

culture in the name of a public entity

b. So-called trust account that is not

The actual owner

(such as a state or local government,

legal or valid trust under State law

school district, or prison) that receives

agricultural program payments

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Form C-5082 - Proofs Of Death-Claimant'S Statement Page 2

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