Fill - Free fillable Receiving the Life Insurance benets intended for you (New York Life) PDF form

New York Life Insurance Company

New York Life Insurance and Annuity Corporation

(A Delaware Corporation)

51 Madison Avenue, New York, NY 10010

NYLIFE Insurance Company of Arizona*

(Not licensed in every state)

4343 North Scottsdale Road, Suite 220

Scottsdale, AZ 85251

Receiving the Life Insurance benets intended for you

Dear Beneficiary:

On behalf of New York Life, please accept our sincere condolences during this difficult time. In the

following pages, you will find the Death Benefit Proceeds Form to be completed and returned by you.

Please provide an original death certificate with this form.

What to expect after you submit your claim

We are committed to processing your claim as quickly as possible. Once we receive complete claim

documents, if additional information is required, a customer service professional will contact you.

Payment of your claim

You will be mailed a check for your share of the proceeds unless you elect a settlement alternative

made available in the original life insurance contract. Proceeds from life insurance products will be credited

with interest as per the contract.

We are here to help

For assistance in completing the form or understanding what information is required, you may contact

a local New York Life Agent or call a customer service professional at (800) CALL-NYL Monday through

Friday, 8 a.m. to 7 p.m. ET. Please say the word “Claims” at any time during the interactive menu to be

transferred directly to the Claims Department. In addition, you may find helpful bereavement information

on our website, www.newyorklife.com.

From all of us at New York Life and our 12,000 financial service professionals across the country, we

are here to be of service to you and your family. Just let us know how we can be of further assistance.

* NYLIFE Insurance Company of Arizona is not authorized in New York or Maine and does not conduct insurance business in New York or Maine.

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Information Regarding Your Life Insurance Payment Options and Settlement Alternatives

Unless settlement alternatives are available in the policy contract and you choose one of these alternatives as described

below, you will be mailed a check for your share of the proceeds. Proceeds will be credited with interest as per the contract.

Please see the enclosed page titled Current Settlement Option Rates for rate information.

Important Information

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account. What this means for you: When you open an account, we will ask for your name, address, date of birth, and other

information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.

Spouse’s Paid-Up Insurance Purchase Option (SPPO)

If the primary beneficiary is the Insured’s spouse or an eligible third party (such as a trust or an individual who is both the

policyowner and the beneficiary), the primary beneficiary may be able to purchase a fully paid-up life insurance policy on the

life of the spouse without underwriting or any medical questions, regardless of health. This option may also be available if the

Insured’s spouse dies at the same time as the Insured or within certain time limits, resulting in additional life insurance benefits.

This is subject to the time limits set forth in the insurance policy.

Not all policies contain the Spouse’s Paid-Up Insurance Purchase Option (SPPO).

The New York version of the SPPO Rider is called the Rider Insured’s Paid Up Insurance Purchase Option (RPPO/RIPPO).

If SPPO is selected, please contact your agent or call (800) CALL- NYL.

Settlement Alternatives

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proceeds to you. Please refer to the original policy for a description of any alternatives. If the policy makes no mention of these,

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has been done, we are obligated to carry out those instructions and will give you full details.

If the policy is not readily available, or for more information on these options, please contact New York Life at (800) CALL-NYL

and a customer service professional will be happy to help you. Please say the word “Claims” at any time during the interactive

menu to be transferred directly to the Claims Department.

A brief description of the settlement alternatives that may be available through the original contract are provided below.

3URFHHGV/HIWRQ'HSRVLWLQGLYLGXDOEHQHƬFLDULHVRQO\Allows you to leave your settlement proceeds with New York Life to

earn interest. Please see page 3 of this packet for more information pertaining to Proceeds Left on Deposit. You may name

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(OHFWHG,QFRPH Equal periodic payments are made according to one of the following methods, as chosen by you:

1) For an elected period of years (1 – 30 years) or 2) For an elected payment amount

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no cash value and there are no additional withdrawals or loans permitted.

*XDUDQWHHG/LIH,QFRPHLQGLYLGXDOEHQHƬFLDULHVRQO\Equal periodic payments are made during your lifetime. You may be

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,I\RXSDVVDZD\SULRUWRWKHHQGRIWKHVHOHFWHGJXDUDQWHHSHULRG\RXUEHQHƬFLDULHVZLOOFRQWLQXHWKHSD\PHQWVXQWLOWKHHQG

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however, there is no cash value and there are no additional withdrawals or loans permitted.

Notice pursuant to Illinois Insurance Code 215 ILCS 5/224: For certain life insurance policies issued in Illinois, any payment made more than 31 days after the

latest of the following to occur will be credited with 10% interest from the date of death through the date of payment: (1) the date we receive your due proof

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that legal impediments to the payment of proceeds are resolved. If proceeds are to be paid in installments, payments made after this 31-day period will be

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H-20250

Important Information about Proceeds Left on Deposit

for Individual Beneciaries (not available if the beneciary is a trust, corporation or estate)

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mention of these, the proceeds will be distributed in a check.

This settlement alternative allows you to leave your settlement

proceeds with New York Life to earn interest. The interest can

be paid to you monthly, quarterly, semi-annually, or annually, or

you can choose to leave the interest on deposit with us.

This alternative may contain a Guaranteed Minimum Interest

Rate (GMIR), which is set when the Settlement Alternatives

are issued. If the company’s declared interest rate, which is set

every December, is higher than the GMIR, the higher rate will

be applied to the amount on deposit. The insurer may derive

income, in addition to any fees charged on the account, from

the total gains received on the investment of the balance

of funds.

Interest earned on proceeds left on deposit may be taxable.

You will receive a Form 1099-INT annually reporting the amount

of taxable interest. This form contains the amount of interest

credited that year and reported to the IRS. You will receive

a Form 1099-R reporting the amount of any taxable gain.

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regarding tax liability and investment options.

Proceeds or interest left on deposit can be withdrawn by

contacting us at (800) CALL-NYL. You will be connected with

our Retirement Solutions team to assist you with your request.

We may be able to process your request over the phone or

if you prefer send a withdrawal request form for completion.

If you provide us with your checking or savings account

information your funds will be sent to you electronically,

otherwise a check will be sent to your mailing address.

Requests submitted in writing should be submitted to the

below address:

New York Life

PO Box 130539

Dallas, TX 75313-0539

If you leave the interest with us, the interest earned can

be withdrawn at any time in sums of $100 or more. The

principal can be withdrawn at any time, and when any partial

disbursements are made, accumulated interest is paid out

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proceeds are available to be withdrawn at any time. There are

no withdrawal penalties if the payee chooses to terminate

this settlement alternative. Other available settlement

alternatives, if applicable, are preserved until the entire

balance is withdrawn or until the balance drops below $2,000.

Proceeds or interest held in this settlement alternative will

remain with the New York Life Insurance Company that issued

the policy. They will not be held in a bank. The funds will be

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long as any proceeds or interest remain. These funds are not

guaranteed by the Federal Deposit Insurance Corporation

(FDIC).

If you choose this settlement alternative, please keep us

informed if you change your mailing address or wish to

withdraw all of your funds. Returned mail or account inactivity

may require us under state law to treat your account as

unclaimed property and eventually release the funds to the

appropriate state. Please be assured that we will try to locate

you before releasing such funds. However, the best way to

maintain control of your funds is to promptly notify us of any

address change or of your intention to completely withdraw

your funds.

The insurer will comply with any valid governmental or

regulating authority’s order with respect to the funds,

including, but not limited to, court orders, liens, tax levies

or garnishments.

FOR FURTHER INFORMATION, PLEASE CONTACT YOUR STATE DEPARTMENT OF INSURANCE.

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Helpful Hints for Completing the Death Benefit Proceeds Form

For the correct approach to complete the Death Benefit Proceeds Form based on your particular situation,

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IRS Form W-9 instructions.

Important Information

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If the individual responsible for filing the claim differs from the taxpayer, a Form W-9 may be required.

Types of trusts in general

 Living trusts are established during the trust creator’s lifetime. A living trust can be revocable or irrevocable. A living

trust may be considered either a grantor trust or a non-grantor trust for federal income tax purposes.

 Grantor trusts are trusts whose separate identity is ignored for federal income tax purposes and whose income is

taxable directly to the grantor/creator of the trust. Although there are exceptions, a grantor trust generally does not

have an EIN/TIN or file its own tax return. A grantor trust generally becomes a non-grantor trust after the grantor’s

death.

 Non-grantor trusts are trusts who have a separate identity for federal income tax purposes and are required to obtain

its own EIN/TIN and file its own tax return.

 Testamentary trusts are established after the creator’s death, typically through the creator’s Will, which must be

probated.

If the beneficiary is a non-grantor trust



If the trust is treated as a non-grantor trust, the IRS requires the name and EIN/TIN of the trust to be provided.

If the beneficiary is a grantor trust

 The deceased Insured’s Social Security Number (SSN) cannot be used. A SSN is typically acceptable for a grantor

trust that has a living grantor (or surviving grantor).

 If the trust is currently treated as a grantor trust, in most situations the IRS requires the grantor to provide his or

her name and SSN and to sign the Death Benefit Proceeds Form (if also trustee). See IRS Form W-9 instructions for

situations when the IRS requires the EIN/TIN and name of the grantor trust to be provided.

If the beneficiary is an estate

 The deceased Insured’s SSN cannot be used.

 If the beneficiary is an estate, the IRS requires the name and EIN/TIN of the estate to be provided.

 If the estate has not and will not be probated, please contact the probate court in the county where the deceased

resided to determine if the estate falls under their small estate guidelines. If you are claiming as heir or affiant and you

have provided the relevant documentation establishing your rights to receive payment, please complete Section 3A

of the Death Benefit Proceeds Form using your individual information and SSN.

Neither New York Life Insurance Company, nor its agents, provide tax, legal, or accounting advice. Please consult your own tax, legal, or

accounting professional before making any decisions.

Questions? &DOO&$//1</DPsSP(7

This is our understanding of the Federal Tax laws. Neither New York Life nor its agents provide tax, legal or accounting advice.

20838LIFE (4/2020)

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State Variations of Fraud Warnings

Kindly refer to the applicable fraud warnings for your state of residence.

Arizona For your protection Arizona law requires the

following statement to appear on this form. Any person

who knowingly presents a false or fraudulent claim for

payment of a loss is subject to criminal and civil penalties.

California For your protection California law requires

the following to appear on this form: 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

ƬQHVDQGFRQƬQHPHQWLQVWDWHSULVRQ.

Colorado It is unlawful to knowingly provide false,

incomplete, or misleading facts or information to an

insurance company for the purpose of defrauding or

attempting to defraud the company. Penalties may

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damages. Any insurance company or agent of an insurance

company who knowingly provides false, incomplete,

or misleading facts or information to a policyholder or

claimant for the purpose of defrauding or attempting

to defraud the policyholder or claimant with regard to a

settlement or award payable from insurance proceeds

shall be reported to the Colorado Division of Insurance

within the department of regulatory agencies.

District of Columbia Any person who knowingly presents

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or knowingly presents false information in an application

for insurance is guilty of a crime and may be subject to

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Florida Any person who knowingly and with intent to

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claim or an application containing any false, incomplete,

or misleading information is guilty of a felony of the third

degree.

Maryland Any person who knowingly or willfully

presents a false or fraudulent claim for payment of a loss

RUEHQHƬWRUZKRNQRZLQJO\RUZLOOIXOO\SUHVHQWVIDOVH

information in an application for insurance is guilty of a

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prison.

New Jersey$Q\SHUVRQZKRNQRZLQJO\ƬOHVD

statement of claim containing any false or misleading

information is subject to criminal and civil penalties.

New York Any person who knowingly and with intent

to defraud any insurance company or other person

ƬOHVDQDSSOLFDWLRQIRULQVXUDQFHRUVWDWHPHQWRIFODLP

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 shall also be subject

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the stated value of the claim for each such violation.

Oregon Any person who knowingly and with intent

to defraud any insurance company or other person

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containing any materially false information or conceals,

for the purpose of misleading, information concerning

any fact material thereto may be subject to prosecution

for insurance fraud. Any person who provides mis-

information material to the content of the contract,

which is relied upon by the insurer, and which is either

material to the risk assumed by the insurer or provided

fraudulently, may be subject to the denial of insurance

EHQHƬWV

Pennsylvania Any person who knowingly and with

intent to defraud any insurance company or other person

ƬOHVDQDSSOLFDWLRQIRULQVXUDQFHRUVWDWHPHQWRIFODLP

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.

Puerto Rico Any person who knowingly and with the

intention of defrauding presents false information in

an insurance application, or presents, helps, or causes

the presentation of a fraudulent claim for the payment

RIDORVVRUDQ\RWKHUEHQHƬWRUSUHVHQWVPRUHWKDQ

one claim for the same damage or loss, shall incur a

felony and, upon conviction, shall be sanctioned for

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WKDQƬYHWKRXVDQGGROODUVDQGQRWPRUHWKDQ

WHQWKRXVDQGGROODUVRUDƬ[HGWHUPRI

imprisonment for three (3) years, or both penalties.

Should aggravating circumstances be present, the

penalty thus established may be increased to a

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are present, it may be reduced to a minimum of

two (2) years.

Other States Any person who knowingly and with the

intent to defraud any insurance company or other person

ƬOHVDQDSSOLFDWLRQIRULQVXUDQFHRUVWDWHPHQWRIFODLP

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. Penalties may include

LPSULVRQPHQWƬQHVRUDGHQLDORILQVXUDQFHEHQHƬWV

if a person provides false information.

23442 (5/2018)

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Social Security Number

Residential

address

STREET APT. CITY S TAT E ZIP

Residential

address

STREET APT. CITY S TAT E ZIP

Mailing

address

LIGLƪHUHQW

STREET APT. CITY S TAT E ZIP

Mailing

address

LIGLƪHUHQW

STREET APT. CITY S TAT E ZIP

Preferred Is this a cell phone? Email

phone no.

▫

Ye s

▫

Preferred Is this a cell phone? Email

phone no.

▫

Ye s

▫

,QFRPH7D[&HUWLƬFDWLRQ(Required)

,I\RXDUHDQLQGLYLGXDOEHQHƬFLDU\FRPSOHWH6HFWLRQ$,I\RXDUHFODLPLQJRQEHKDOIRIDWUXVWHVWDWHRUFRUSRUDWLRQFRQWLQXHWR6HFWLRQ%

Relationship to Insured

▫

Spouse

▫

Child

▫

Grandchild

▫

Parent

▫

Sibling

▫

Other

Name Social Security

Number

FIRST M.I. LAST

Name Date

of birth

FIRST M.I. LAST MM DD YYYY

Death Benet Proceeds Form - Life

List the policy number(s) or claim number under which you are making a claim

Provide information about the deceased.

Cause/ Date

manner of birth

of death

MM DD YYYY

Natural (type of illness or disease - check one) If not natural (check one)

▫

Cancer

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Heart disease

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Accident

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Suicide

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Respiratory disease

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Homicide

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Unknown

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Other

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Corporate Officer

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Estate Representative

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Trustee

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Collateral Assignee

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Other

Continue to next page for payment options and signature.

Date of trust State where trust Is this a grantor trust for federal Is there a surviving grantor?

agreement was established

income tax purposes?

▫

Yes

▫

No

▫

Yes

▫

No

MM DD YYYY

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For more information, please see page 4

titled: +HOSIXO+LQWVIRU&RPSOHWLQJWKH

'HDWK%HQHILW3URFHHGV)RUP

Entity name as shown on income tax

return (e.g. name of trust, estate of

deceased individual, corporation name, etc.)

Name of representative/

trustee of entity

Capacity under which you are making this claim CHECK ONE.

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20838LIFE (4/2020)

20838LIFE 0420 07

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Death Benet Proceeds Form - Life

Please indicate your settlement option choice below.

If no selection is made, the proceeds will be distributed to you as a check

▫

Check

▫

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Settlement Alternatives FKHFNRQH 3URFHHGV/HIWRQ'HSRVLW (OHFWHG,QFRPH *XDUDQWHHG/LIH,QFRPH

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 LQGLYLGXDOEHQHILFLDULHV LQGLYLGXDOEHQHILFLDULHV

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Other

The original life insurance contract may have specified that certain settlement alternatives are available for distributing the proceeds to the

beneficiaries. Please refer to the original policy for a description of any alternatives. If the policy makes no mention of these, the death benefit

proceeds will be distributed in a check. If the policy is not readily available, or for more information on these options, please contact New York Life

at (800) CALL NYL and a customer service professional will be happy to help you. Please say the word “Claims” at any time during the interactive

menu to be transferred directly to the Claims Department.

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Questions? &DOO&$//1</DPsSP(7

Read and sign.

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 shall also be subject to a civil penalty not to exceed five thousand

dollars and the stated value of the claim for each such violation. Please refer to the enclosed page entitled STATE VARIATIONS OF FRAUD

WARNINGS for specific notices required in certain jurisdictions.

Under penalties of perjury, I (as beneficiary named) certify that: (1) my Social Security Number or Taxpayer Identification Number shown on

this death benefit proceeds form is my correct Taxpayer Identification Number, (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 IRS that I am subject to backup withholding as a result of a failure to

report all interest or dividend income; or (c) the IRS has notified me that I am no longer subject to backup withholding, (3) I am a U.S. person

(includes a U.S. resident alien), and (4) the FATCA code entered on this form (if any) indicating that I am exempt from FATCA reporting is

correct. (Please note: If being submitted for a U.S. policy, this last certification (4) does not apply.)

▫

Check this box if the IRS has notified you that you are subject to backup withholding.

If I am not a U.S. citizen, U.S. resident alien or other U.S. person, I am submitting the applicable Form W-8 with this form to certify my

foreign status and, if applicable, claim treaty benefits.

The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid

backup withholding.

Mail: 1HZ<RUN/LIH&ODLPV%HQHILWV32%R['DOODV7;

Overnight mail:1HZ<RUN/LIH&ODLPV%HQHILWV*UHHQYLOOH$YH6XLWH'DOODV7;

Title Name

Signature (Required) &RUSRIILFHU(VWDWH5HS7UXVWHHHWF (Print) Date

Title Name

Signature (If Required) &RUSRIILFHU(VWDWH5HS7UXVWHHHWF (Print) Date



20838LIFE (4/2020)

20838LIFE 0420 08

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Receiving the Life Insurance benets intended for you (New York Life)

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