F
UNERAL
F
IRM
A
SSIGNMENT
Address City State Zip
Funeral Firm
Telephone
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Signature of Funeral Director Date
CLAIM FORM
(See Instructions on Reverse Side)
A8006-02
© 2009 Forethought
0309
WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person.
Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a
claim was provided by the applicant.
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Cause of Death Natural Accidental Suicide
INSURED
Policy/Certificate Number
Age Date of Birth Social Security Number Date of Death
If there is no estate, we may pay excess benefits to a relative of the insured instead of the estate itself (except for individual policies in Kansas).
Therefore, with the exception of Kansas individual policies, if the estate is named as beneficiary, please indicate who should receive any
excess.
REQUEST FOR TAXPAYER IDENTIFICATION NUMBER AND CERTIFICATION BY BENEFICIARY/ESTATE
Certification Instructions. You must cross out item (2) above if you have been notified by the IRS that you are subject to backup
withholding because of underreporting interest or dividends on your tax return. However, if after being notified by the IRS that you were
subject to backup withholding you received another notification from the IRS that you are no longer subject to backup withholding, do not
cross out item (2).
The number shown on this form is my correct Taxpayer Identification Number, and
I am not subject to backup withholding either because 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 the IRS has notified me that I am no longer subject
to backup withholding.
Certification. Under penalties of perjury, I certify that:
Enter your Taxpayer Identification Number in the box below. For most individuals, this is your Social Security number.
Social Security Number/Taxpayer Identification Number
1)
2)
FORETHOUGHT FINAL EXPENSE
PAYMENT AUTHORIZATION
By signing below, I certify that I am the beneficiary named in the above-referenced certificate and the above information is true and complete to
the best of my knowledge. A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false,
incomplete or misleading information commits a felony.
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IRS regulations require that we obtain the beneficiary’s Social Security number in order to generate a 1099 for any interest paid on life
insurance death benefits or growth and/or interest on annuity contracts in the amount of $10.00 or more. If paying the estate, please provide
a Tax Identification Number of the estate in the box below.
Page 1 of 2
TAXPAYER IDENTIFICATION
Signature of Beneficiary Date
/ /
Name of Insured
OPTIONAL – Complete ONLY if assigning benefits to the Funeral Firm
/ /
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( )
AUTHORIZATION OF PAYMENT
Pay all proceeds to me; or
City State Zip Telephone
Printed Name of Beneficiary (Full legal name)
Mailing Address
( )
I hereby assign (the cost of the funeral/cemetery merchandise and services provided) of the life insurance
proceeds to the funeral provider identified below. Any remaining proceeds are to be paid to me.
$
