Fillable Beneficiary Claim Form (Page 3 of 3) in pdf

BENEFICIARY CLAIM FORM

5. FRAUD WARNING STATEMENTS Continued

Oregon: it is fraudulent to fill out this form with information known to be false or omit important facts with the knowing

intent to defraud. criminal and/or civil penalties may result from such acts. An insurer may deny a claim on the basis of

misstatements, misrepresentations, omissions, or concealments if such misinformation is material to the contract, the insurer

relies on the misinformation, and the information is either material to the risk assumed by the insurer or the misinformation

was provided fraudulently. committing any of these acts may result in prosecution for insurance fraud.

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.

Maine, Tennessee, and Washington: 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.

6. SIGNATURES AND CERTIFICATION

the undersigned hereby applies for payment of this death benefit from the American equity investment Life insurance

company and agrees that the written statements and all other papers called for by the instructions herein, shall constitute

and are hereby made a part of these proofs of Death, and further agrees that the furnishing of this form, or any other

forms, by said company, shall not constitute nor be considered an admission by it that there was any life contract in force

for the person named above, nor a waiver of any of its rights or defenses.

By signing this form you are indicating that you read the appropriate fraud statement designated for your state.

Certification - under penalties of perjury, i certify that:

1. the number shown on this form is my correct taxpayer identification number; and

2. i am not subject to backup withholding due to failure to report interest and dividend income; and

3. i am a u.S. citizen or other u.S. person (defined in the W-9 instructions).

Certification Instructions: you must strike out item 2 above if you have been notified by the irS that you are currently

subject to backup withholding.

The Internal Revenue Service does not require your consent to any provision of this document other

than the certifications required to avoid backup withholding.

____________________________________________________

_________________________________

Signature and title*

Date

*If you are signing on behalf of another individual or entity, please indicate your position (e.g. executor, trustee, guardian, conservator, power of attorney, etc.) following your signature.

Reset

200

09.11.13

AmericAn equity inVeStment Life inSurAnce compAny • p .o. Box 527 • peLL city, AL 35125-0527 • 877-508-9888

3 of 3 PAGES • NOT COMPLETE WITHOUT ALL PAGES

Beneficiary Claim Form Page 3

Related Articles

Related forms

Related Categories