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Dear Sir or Madam:
We are sorry to learn about your recent loss and extend our condolences. To begin processing the claim
for benefits under this policy, we need the following documentation and forms completed and returned by
the beneficiary.
CLAIMANT’S STATEMENT: Note: Must be signed by the beneficiary and witnessed by a disinterested
party or payment may be delayed. The Claimant’s Statement does not need to be notarized.
CERTIFIED COPY OF THE DEATH CERTIFICATE: for the insured that identifies both cause and
manner of death. Note: We cannot accept a photocopied death certificate for the insured person. A
“certified” death certificate will have a “raised/embossed” or colored seal on the front. Generally, only one
copy of the certified death certificate is necessary, even in the case of multiple beneficiaries. If any
primary beneficiary pre-deceased the insured, we will require a photocopy of that beneficiary’s death
certificate. Death certificates become part of the file and cannot be returned.
ORIGINAL INSURANCE POLICY: Note: Please be sure to mark the Claimant’s Statement where
indicated if the policy is lost. If the claim is on a rider and the policy still provides coverage on additional
individuals do NOT return the original policy. Please provide only a photocopy of the Policy Data Page
and applicable insurance rider.
COPY OF THE OBITUARY: (if available).
BENEFICIARY NAME CHANGE: Note: If the beneficiary’s name changed after the owner designated the
beneficiary, please return documentation of the name change (Marriage Certificate, Divorce Decree, etc.)
Please mail these documents to Americo Life, Attn: Claims, at one of the following addresses:
Regular Mail: Overnight Mail:
P.O. Box 410288 300 W. 11th Street
Kansas City, MO 64141-0288 Kansas City, MO 64105
Other than the original policy and Certified Death Certificate, faxed documents, including the Claimant’s
Statement, are generally acceptable and may be faxed to (800)-395-9238 or emailed to
forms@americo.com.
To assist with filing your claim, please read the Instructions to the Claimant Statement. If you have any
additional questions or need further assistance, please contact our office at (800) 231-0801.
Sincerely,
Claims Department
P. O. Box 410288
Kansas City, MO 64141-0288
800-752-1387
Americo Financial Life and Annuity Insurance Co. (formerly The College Life Insurance Company of America) • Great Southern Life Insurance Co. • The Ohio State Life Insurance
Co. • United Fidelity Life Insurance Co. • National Farmers Union Life Insurance Co. • Financial Assurance Life Insurance Co. • Investors Life Insurance Company of North America •
Companies Administered by the Americo Group of Companies: Protective Life Ins. Co. (formerly Ohio Life Ins.) • Berkley Life and Health Ins. Co. (formerly Investors Guaranty Life)
• First Health Life & Health Insurance Co. (formerly Loyalty Life Ins. Co.) • Fremont Life Ins. Co. • Renaissance Life & Health Insurance Company of America (formerly Central
National Life of Omaha) • Pavonia Life Insurance Co. of NY (formerly First Central National Life of New York) • Conseco Life Insurance Co. (formerly Massachusetts General Life
Insurance Co.) • Life Insurance Company of North America • Athene Annuity and Life Company (formerly American Investors Life)
INSTRUCTIONS & CLAIMANT’S STATEMENT
CLAIMANT’S STATEMENT must be completed by the person(s) or entity to whom the insurance is
payable. If there is more than one beneficiary, you may make copies of this form as needed.
Please review the instructions below for the applicable beneficiary type before completing the Claimant’s
Statement.
• Individual beneficiary who is the age of majority or older: The statement must be completed and
signed by such beneficiary and witnessed.
• Trust: The statement must be completed by the Trustee(s) and include the full name of the trust
along with the Trust documents.
• Estate: The statement must be completed by the Executor(s) or Administrator(s), and submitted
with the Letters issued by the Court appointing that individual.
• Company or Corporation: The statement must be signed by two officers and include each officer’s
title.
• Minor: The statement may be completed by the Court appointed Guardian of the minor’s Estate
and submitted with a copy of the Court issued appointment or in accordance with other applicable
state law. Proceeds may also be held with the Company at interest until the minor reaches the age
of majority, which varies by state.
If a policy has been collaterally assigned by the owner prior to the death of the decedent, a Statement of
Interest is also required. This document provides a statement of the assignee’s interest and may be
obtained by contacting our office.
CLAIMANT’S STATEMENT
Part A - Information about the Deceased
Name of Deceased (State all names used by the deceased during their life
including maiden name, nickname, alias, or other name)
Policy Number(s)
Deceased’s Date of Birth
Deceased’s Social Security Number
Date of Death
Cause of Death as listed on Death Certificate
Manner of Death
[ ] Natural [ ] Homicide [ ] Accident [ ] Suicide
Part B – Information about the Beneficiary
Individual, Trust or Company Name
Telephone Number
Email Address
Beneficiary Social Security Number/Tax I.D
Relationship to the Deceased
Beneficiary Date of Birth/Trust Date
Part C - Policy/Death Certificate
Please select the appropriate statements:
Enclosed is a certified copy of the death certificate of the insured.
Enclosed is (are) the original policy(ies).
The original policy(ies), or copies, cannot be located
If beneficiary is a trust, I have enclosed trust documents.
If beneficiary is a trust, I certify that the trust is still in full force and effect.
Part D - Settlement Options
Please select one of the following options:
Make proceed immediately available*
Alternative Settlement Options (e.g. Installment, Life Income, Funds left on Deposit): Please send me additional
information on these additional options.
Other (please specify)
*
Unless a lump sum payment is specially requested, an interest-bearing Financial Access Account will be automatically
established on the beneficiary’s behalf that gives the beneficiary time to make important financial decisions with respect to t
he
pr
oceeds. The payment of policy benefits of $5,000 or more will be made to the beneficiary through the account. You will
be
abl
e to draw on that account at any time and for any amount (in excess of $250) up to the account’s then current balance. Th
e
t
erms and conditions of the Financial Access Account are described in the attached materials
Contact our office at 800.231.0801 for specific details regarding any of these Settlement Options.
IRS Certification:
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me),
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 (that is, an individual who is a U.S. citizen or U.S. resident alien, a
partnership, corporation, company, or association created or organized in the United States or under the laws of the
United States, an estate [other than a foreign estate], or a domestic trust [as defined in Regulations section 301.7701-7]).
Certification instructions: You must cross out item 2 above if you have been notified by the IRS that you are currently
subject to backup withholding because you have failed to report all interest and dividends on your tax return. Your
signature at the bottom of this form certifies that you have read and attest to the information provided.
FRAUD NOTICE
Several states require that a notice be provided to each claimant to protect against Fraud. The undersigned acknowledge the
Fraud Notice document has been received, read and is incorporated by reference if the State in which the undersigned resides in
is listed on that notice. It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for
the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits.
SIGNATURE
The undersigned agrees that this Claimant’s Statement constitutes their claim for proceeds, if any, under each of the above-
listed policies as such were contractually in force at the time of the Deceased’s death and that furnishing of this Statement does
not waive any contract provisions.
Beneficiary Signature Date
(PLEASE SIGN AS YOU WOULD A CHECK)
Disinterested Witness Date
Witness Address and Phone Number [MUST BE SIGNED BY A WITNESS]
14-040-4
FRAUD NOTICE FORM
Before signing any claim form, please read the applicable fraud warning for the state where you reside
and for the state where the insurance policy under which you are claiming benefit was issued. Many
States require the Insurer to provide claimants with a Fraud Statement such as the following:
Any person who, with intent to defraud or knowing that the person is facilitating a fraud against an Insurer,
submits an application or files a claim containing a false or deceptive statement is guilty of insurance
fraud.
The following States require the insurer to provide claimants with the specific language below:
Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit
or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
Alaska: A person who knowingly and with intent to injure, defraud or deceive an insurance company files
a claim containing false, incomplete, or misleading information may be prosecuted under state law.
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.
Arkansas, Louisiana, Rhode Island, and West Virginia: Any person who knowingly presents a false or
fraudulent claim for payment for a loss of benefit or knowingly presents false information in an application
for insurance is guilty of a crime and may be subject to fines and confinement in prison.
California: For your protection, California law requires the following to appear on this
form: Any person who knowingly presents 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.
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
include imprisonment, fines, denial of insurance, and civil 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 purposes 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.
Delaware: Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a
statement of claim containing any false, incomplete, or misleading information is guilty of a felony.
District of Columbia: 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.
Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a
statement of claim or an application containing any false, incomplete, or misleading information is guilty of
a felony of the third degree.
Hawaii: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for
payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.
Idaho: Any person who knowingly and with intent to defraud, or deceive any insurance company, files a
statement containing any false, incomplete, or misleading information is guilty of a felony.
Indiana: 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.
Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person
files a 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.
Version 03/2017
Maine: It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a
denial of insurance benefits.
Maryland: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly and willfully presents false information in an application for insurance is
guilty of a crime and may be subject to fines and confinement in prison.
Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer
is guilty of a crime.
New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company,
files a statement of claim containing any false, incomplete or misleading information is subject to
prosecution and punishment for insurance fraud, as provided in NH R.S.A Section 638:20.
New Jersey: Any person who knowingly files a statement of claim containing any false or misleading
information is subject to criminal and civil penalties.
New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or knowingly presents false information in an application for insurance is guilty of a crime and may
be subject to civil fines and criminal penalties.
New York: 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 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.
Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer,
submits an application or files a claim containing a false or deceptive statement is guilty of insurance
fraud.
Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete, or
misleading information is guilty of a felony.
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.
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 of a loss or any other benefit, or presents more than one claim for the same damage or loss,
shall incur a felony and, upon conviction, shall be sanctioned for each violation with the penalty of a fine
of not less than five thousand ($5,000) dollars and not more than ten thousand ($10,000) dollars, or a
fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be
present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating
circumstances are present, it may be reduced to a minimum of two (2) years.
Tennessee, Washington, Virginia: 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.
Version 03/2017
Financia
l Access Account and
life
Insurance
Disclosure
Statement
The death of
a
spouse
,
parent, child, partner, or other
loved one is a difficult time. In addition to the emotional
stress present during the weeks, months, or years
following a death, financial burdens may also arise. Life
insurance is intended to assist with these financial
burdens. While life insurance policies provide for a single
payment of the death benefit, policies may also offer other
payout options that are intended to fit your needs and
those of your family. The following information describes
the Financial Access Account we are offering you as an
option to a single payment.
What is the Financial Access Account?
The Financial Access Account (FAA) is a temporary
repository of funds available to any beneficiary entitled
to receive benefits of $5,000 or more. The account’s
function is to give you, the beneficiary, the time you
need to consider all of the financial options available.
The payment of the full benefit due under the policy will
be accomplished by delivery of a “checkbook” of drafts
which are similar to checks by different in some
respects. You can write them just as you would checks.
The use of the Financial Access Account provided you
the flexibility to make the right decision regarding your
long-term financial needs while earning interest on the
life insurance proceeds.
How does the Financial Access Account work?
Your FAA is a draft account which is maintained by
Northern Trust Bank. A draft account is similar to a
checking account, and earns interest. However, instead
of checks, you will receive a book of drafts. You write as
a many drafts as you like in the same manner as you
would write checks when you need to access your
money. Our obligation to pay the total policy or contract
proceeds is satisfied by depositing the total proceeds in
the FAA. Once payment is made to you via the FAA,
you will have immediate access to the entire amount,
plus any accumulated interest. When your draft is
presented for payment, it is paid through Northern Trust
Bank. Please check with your financial institution on any
potential delays in accessing the funds once the draft(s)
has been presented.
Are there minimum draft requirements?
Yes, each draft must be a minimum of $250. You may
keep your FAA open as long as you like. The only
requirement is that you maintain a minimum account
balance of $250. If the account balance falls below
$250, we will send you a check for the remaining
proceeds, plus all accrued interest, within 45 days of the
account closure.
11-077-1(11/18)©Americo
Can I write one draft to access the entire amount?
Yes. One draft may be written at any time to access the
entire amount of the FAA, including interest.
Are my funds guaranteed by the Federal Deposit
Insurance Corporation (FDIC)?
FAA funds are held in our general account and are not
guaranteed by the Federal Deposit Insurance
Corporation (FDIC), but are guaranteed by State
Guaranty Associations. State Guaranty Association
coverage limits vary by state.
Is the interest earned on my FAA taxable?
The interest you earn on your FAA may be subject to
income taxation. We recommend you consult a tax,
investment, or other financial advisor regarding tax
liability.
What fees are charged on the FAA?
Your FAA has on charges for drafts or monthly service
charges. However, your account will be charged the
following fees for each of the particular services
described below:
•
$10.00 fee for any draft returned unpaid;
•
$12.00 fee for each stop payment order;
•
$2.00 fee for a copy of any draft or statement
We reserve the right to change these fees at any time.
In addition, we may derive income, in addition to any
fess charged on the account, from the total gains
received on the investment of the balance of funds in
the FAA.
How frequently will I receive statements?
Each month that there is activity on your account other
than the crediting of interest; you will receive a monthly
statement. Otherwise, you will receive quarterly account
statement showing the current balance, the interest
credited, the drafts written, and any other account
activity.
How is interest calculated?
The interest rate currently being paid on FAAs is
0.55%. Interest is earned on your FAA from the date it
is established until the date drafts are cleared. Interest
is compounded daily and is credited to your account
monthly. Interest is based on the balance in your FAA at
the end of each day. The guaranteed minimum interest
rate is 0%. Interest rates are reviewed by the Company
on a regular basis and are set at the Company’s
discretion.
What happens if my FAA becomes inactive?
If your account has not had any activity, such as a
withdrawal or affirmative contact, within a two-year
period, we will contact you to confirm your interest in
maintaining this account. If we are unable to contact
you, or you do not respond, we will proceed according
to the unclaimed property laws in your state.
Are the available settlement options preserved until
the entire balance of FAA is withdrawn?
All settlement options under the original policy are
preserved until the entire balance is withdrawn or the
balance drops below the company’s’ minimum balance
requirement. Settlement options may include one or
more of the following:
Lump sum –
through this option, you would receive the
entire proceeds in one payment.
Life only –
through this option, proceeds plus interest
are paid in installments as long as you are living.
Payments cease at your death.
Life income with a period certain –
through this
option, proceeds, plus interest, are paid in installments
as long as you are living. If you die within the period
certain you selected, we will continue payments to your
beneficiary until the time period selected is concluded.
Installment payout for a fixed amount or period –
through this option, you may choose to receive either a
fixed settlement amount, or a settlement amount for a
fixed period of time.
Interest only payout –
through this option, proceeds
are left with the insurance company and you will receive
interest payment which the insurer will pay you on a
periodic basis. Proceeds will be paid at the end of the
period selected.
Where can I obtain more information about these
accounts and the services provided?
If you have questions, you can contact us as follows”
Phone:
800.366.6400
Web:
www.americo.com
Physical Address:
PO Box 410288, Kansas City, MO
64141
How can I learn more about the coverage
limitations applicable to my FAA?
You are also advised to contact the National
Association of Life and Health Insurance Guaranty
Associations (at www.nolhga.com) (telephone number
703.481.5206) to learn more about coverage limitations
on your account.
FOR FURTHER INFORMATION, PLEASE CONTACT
YOUR STATE DEPARTMENT OF INSURANCE.
For Over 100 years, Americo Life Inc.’s family of
insurance companies has been committed to providing
the life insurance and annuity products you need to
protect your family and future. The Americo family of
companies includes:
•
Americo Financial Life and Annuity Insurance
Company
(
f
ormerly
The College Life Insurance
Company of
America)
•
Great Southern Life Insurance Company
•
The Ohio State Life Insurance Company
•
United Fidelity Life Insurance Company
•
National Farmers Union Life Insurance Company
•
Financial Assurance Insurance Company
•
Investors Life Insurance Company of North America
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Completed 28 April 2021

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