Death Benefit Claim (Page 9 of 13) in pdf

The Fixed Annuity Options are as follows:

Income of an Amount Certain

— The Claimant must indicate a specific amount to be paid on a monthly, quarterly, semi-annually, or annual basis. The

amount chosen must be received over a period not greater than 20 years. If the Claimant dies before the entire annuitized balance is distributed, the

Claimant’s beneficiary will receive all remaining annuity payments, if any. The number of payments are not guaranteed.

Payment of a Period Certain (Years)

— The Claimant will receive payments on a regular installment basis (monthly, quarterly, semi-annually or

annually). Payment amounts will depend on the length of time in years during which the Claimant elected to receive payments, the periodic basis that

the Claimant chooses, and the performance of the investment options. Payment amounts are not guaranteed.

Fixed Life Annuity with Guaranteed Period

— The Claimant will be paid monthly annuity payments for the guaranteed annuity payment period you

select (5,10,15,or 20 years) or for their lifetime, whichever is longer. Upon the Claimant’s death, all payments remaining payable under the guaranteed

period will be paid to the Claimant’s beneficiary, if any. If the Claimant chooses this option, the Claimant must attach a copy of his or her birth certificate

or driver’s license.

Fixed Life Annuity: Life Only, No Death Benefit

— The Claimant will be paid monthly annuity payments during his or her lifetime. Upon the

Claimant’s death, all benefit payments cease. If the Claimant chooses this option, the Claimant must attach a copy of his or her birth certificate or

driver’s license.

Joint Life

— The Claimant will receive monthly annuity payments for his or her lifetime. Upon the death of the annuitant, the surviving co-annuitant

will receive a pre-elected percentage (100% or 50%) of the original payment amount for his or her lifetime. For example, if the Claimant elects a joint

and 50% annuity, the surviving annuitant will continue to receive fixed monthly payments equaling one half of the amount received while both annuitants

were living. The Claimant must attach a copy of both annuitants’ birth certificates or driver’s licences.

Additional Fixed Annuity Options may be available under your Plan.

Direct Rollover

Direct Rollover to an Eligible Plan or IRA

— The Claimant must determine whether the plan or IRA accepts eligible rollover distributions.

Beginning in the later of the year that the Claimant attains age 70

, the Claimant may not roll over that portion of a distribution equal to his or her

required minimum distribution amount. In the event that the participant had not received but was required to receive his or her required minimum

distribution prior to his or her death, the required minimum distribution will be paid out before the rollover will be processed. If the Claimant elects a

distribution in the form of an annuity, as of January 1 of the calendar year in which he or she attains age 70

, the IRS will treat the entire portion of each

and every annuity payment as a required minimum distribution. Therefore, the entire amount of each annuity payment is not eligible for rollover.

If the Claimant is requesting a direct rollover, an eligible rollover distribution is paid from the Plan directly to the eligible Code section 401(a), 401(k),

403(b) or governmental 457(b) plan or to a Traditional IRA.

Indicate the dollar amount the Claimant wants to roll over (minimum $200.00) and provide the company name, account number, mailing address, city, state,

zip code and a phone number for the direct rollover. In the event of an inconsistency between information contained on the Form and any other information

provided with the Form, the information on the Form will be used. Once the Service Provider has processed a direct rollover, it cannot be returned.

If the Claimant chooses this type of claim, a Form 1099-R will be issued for reporting purposes; however, no federal income tax will be automatically

withheld from amounts directly rolled over.

Claim Delivery

The delivery of the claim may depend on the type of claim elected on the Form. Certain delivery options are not available on all types of claims. Below

is a description of each delivery option.

Check

— The Claimant can receive the claim by check regardless of the distribution method selected on the Form.

Express Delivery

— Express delivery is available for full distributions only. The amount of the claim check will be reduced by $25.00 for this service.

Express delivery is available for Monday through Friday delivery only and is not available to PO. boxes or addresses within Colorado. Delivery is not

guaranteed to all areas.

Automated Clearing House (ACH) (Automatic bank deposit)

— Check this box if the Claimant wants his or her check to be electronically deposited

into their checking or savings account. The Claimant may not designate a business account or an IRA. For direct rollovers to an IRA, contact the local

representative for the appropriate form. You can only select ACH if the Claimant selected a periodic payment or a fixed annuity. Complete the bank name,

account number, ABA routing number, bank mailing address, city, state, zip code, and attach avoided check to the Form where indicated.

ACH is a form of electronic funds transfer by which the Service Provider can transfer your payments directly to the Claimant’s financial institution. Allow

at least 15 days from the date the Service Provider receives the Claimant’s properly completed Form to begin using ACH for the Claimant’s payments.

Upon receipt of a properly completed Form, the Service Provider will notify the financial institution of the ACH request with the account information

provided. The pre-notification process takes approximately 10 days. During the pre-notification process, the financial institution will confirm with the

Service Provider that the account and routing information submitted is correct and that it will accept the ACH transfer. After this confirmation is received,

the payments will be transferred to the Claimant’s financial institution within 2 days of the first payment date. If the payments are withdrawn from investments

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Page 4 of 8 Guide

Benefit Claim_12.30.10

Death Benefit Claim Page 9

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