Fillable Beneficiary Statement printable pdf download

Beneficiary Statement

Phoenix Life Insurance Company (Phoenix)

PHL Variable Insurance Company (Phoenix)

Phoenix Life and Annuity Company (Phoenix)

Regular Mail: PO Box 8027, Boston MA 02266-8027

Overnight Mail: 30 Dan Road, Suite 8027, Canton MA 02021-2809

Claim Number: ______________________

A. Insured Information

List below ONLY the policies/contracts under which you the beneficiary are making claim.

____________________________

______________________________

____________________________

______________________________

Name of Deceased

Deceased’s Social Security Number

Birthdate of Deceased

Deceased’s Date of Death

Cause of Death

Manner

Natural/Illness

Accidental

Suicide

Homicide

B. Beneficiary Information

– Please print

Full Name of Individual, Entity, Corporation or Trust

Your Daytime Telephone Number

Date of Birth / Date of Trust

Your Sex

Male

Female

Please supply Social Security Number if you are the Individual Beneficiary

Please supply Taxpayer Identification Number if this is a Trust, Estate, or Corporate Beneficiary

Your Physical Address (No., Street, City, State and ZIP Code - P.O. Box not accepted)

Mailing Address for Payment (No., Street, or P.O. Box, City, State and ZIP Code) For Your Security. If the payment is not being mailed to you at your residence address, please explain briefly

why and advise to whom it is being mailed (for example; Mail to my PO Box, Mail to me in care of my child with whom I am staying, Mail to me in care of my attorney’s office).

CERTIFICATION - Under penalties of perjury, I certify that:

1) the number shown on this form is my correct Social Security Number or taxpayer identification number, 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 (including a U.S. Resident Alien) as defined in the instructions to the IRS Form W-9, and

4) I am exempt from FATCA reporting (if applicable).

Certification Instructions: You must cross out item (2) if you have been notified by the IRS that you are currently subject to backup withholding because

of under-reporting interest or dividends on your tax returns.

I am aware that if my taxpayer ID or Social Security Number is not supplied, the interest earned may be subject to federal or state withholding.

C. Policy Status (

all policies should be returned unless they are lost)

If the policy/contract or policies/contracts cannot be located and are presumed lost, misplaced or destroyed, please complete this section.

Lost Policy/Contract Agreement

Policy/Contract Number(s) ___________________________________________________________________________________________________

Insured __________________________________________________________________________________________________________________

The undersigned affirms that, except for the respective interests of the undersigned as shown on Phoenix’s records, no other party has any interest in the

policy’s/contract’s ownership rights or benefits, through assignment, transfer, pledge or encumbrance of any nature whatsoever.

The undersigned requests that Phoenix pay, without production of the lost policy/contract, the proceeds due as a result of the death of the insured.

The undersigned do further request that until the whereabouts of the lost policy/contract becomes known to Phoenix by written notice received at its Home

Office, Phoenix will waive any requirements of the lost policy/contract that such policy/contract be delivered to Phoenix as a prerequisite to any transaction

involving such policy/contract.

FG11

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Beneficiary Statement

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