Form 712 - Life Insurance Statement
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3712
Form
Life Insurance Statement
(Rev. April 2006)
OMB No. 1545-0022
Department of the Treasury
Internal Revenue Service
Part I
Decedent—Insured
(To be filed by the executor with Form 706, United States Estate (and Generation-Skipping Transfer) Tax Return, or
Form 706-NA, United States Estate (and Generation-Skipping Transfer) Tax Return, Estate of nonresident not a citizen of the United States.)
1
Decedent’s first name and middle initial
2
Decedent’s last name
3
Decedent’s social security number
4
Date of death
(if known)
5
Name and address of insurance company
6
Type of policy
7
Policy number
8
Owner’s name. If decedent is not owner,
9
Date issued
10
Assignor’s name. Attach copy of
11
Date assigned
attach copy of application.
assignment.
12
Value of the policy at the
13
Amount of premium (see instructions)
14
Name of beneficiaries
time of assignment
15
$
15
Face amount of policy
16
$
16
Indemnity benefits
17
$
17
Additional insurance
18
$
18
Other benefits
19
$
19
Principal of any indebtedness to the company that is deductible in determining net proceeds
20
$
20
Interest on indebtedness (line 19) accrued to date of death
21
$
21
Amount of accumulated dividends
22
$
22
Amount of post-mortem dividends
23
$
23
Amount of returned premium
24
$
24
Amount of proceeds if payable in one sum
25
$
25
Value of proceeds as of date of death (if not payable in one sum)
26
Policy provisions concerning deferred payments or installments.
Note. If other than lump-sum settlement is authorized for a surviving spouse, attach a copy of
the insurance policy.
27
$
27
Amount of installments
28
Date of birth, sex, and name of any person the duration of whose life may measure the number of payments.
29
Amount applied by the insurance company as a single premium representing the purchase of
29
$
installment benefits
30
Basis (mortality table and rate of interest) used by insurer in valuing installment benefits.
Were there any transfers of the policy within the three years prior to the death of the decedent?
Yes
No
31
32
Date of assignment or transfer:
/
/
Month
Day
Year
33
Was the insured the annuitant or beneficiary of any annuity contract issued by the company?
Yes
No
34
Did the decedent have any incidents of ownership on any policies on his/her life, but not owned by
him/her at the date of death?
Yes
No
35
Names of companies with which decedent carried other policies and amount of such policies if this information is disclosed by your records.
The undersigned officer of the above-named insurance company (or appropriate federal agency or retirement system official) hereby certifies that this statement sets
forth true and correct information.
Signature
Title
Date of Certification
712
For Paperwork Reduction Act Notice, see page 3.
Cat. No. 10170V
Form
(Rev. 4-2006)
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