IDENTIFICATION A FRATERNAL BENEFIT ... - catholicforester.org

1 IDENTIFICATION . A FRATERNAL BENEFIT LIFE INSURANCE SOCIETY SINCE 1883. WORKSHEET. 355 Shuman Boulevard, PO Box 3012, Naperville, IL 60566-7012. Toll-free 800-552-0145 TTY 800-617-4176 On April 2, 2007, COF revised the company's Anti-Money Laundering (AML) policy. The revisions include an IDENTIFICATION Worksheet (IW) as part of the Know Your Customer requirements of the AML law. The IW will be required on all COF. products except Forester Membership and Travel Care travel accident policies, Pathways/FirstVantage policies, and any policy where the annualized premium and/or deposit is more than $3,000. If you have questions, please contact the home office Compliance Department at 800-552-0145.

2 IW-50 (5/11) 11-026 1 of 3. IDENTIFICATION . A FRATERNAL BENEFIT LIFE INSURANCE SOCIETY SINCE 1883. WORKSHEET. 355 Shuman Boulevard, PO Box 3012, Naperville, IL 60566-7012. Toll-free 800-552-0145 TTY 800-617-4176 ACCEPTABLE IDENTIFICATION . agent has the right to accept or refuse any documents. Passport Valid State-issued Driver's License Social Security Card issued by (unexpired or expired) with photograph the Social Security Administration Valid Local-, State-, or Federal-issued Certificate of Birth Abroad issued by Certificate of Citizenship IDENTIFICATION Card with photograph the State Department School IDENTIFICATION Card with Certificate of Naturalization Citizen IDENTIFICATION Card photograph Birth Certificate (Original or certified copy issued by a Unexpired Foreign Passport Voter's Registration Card state, county, municipal authority, or outlying possession of the bearing an official seal).

3 Permanent Resident Card or Alien Resident Citizen IDENTIFICATION Registration Receipt Card with Military Card or Draft Record Card photograph Valid Canadian Driver's License Coast Guard Merchant Mariner Native American Tribal Document issued by a Canadian Government Card Authority IW-50 (5/11) 11-026 2 of 3. IDENTIFICATION . A FRATERNAL BENEFIT LIFE INSURANCE SOCIETY SINCE 1883. WORKSHEET. 355 Shuman Boulevard, PO Box 3012, Naperville, IL 60566-7012. Toll-free 800-552-0145 TTY 800-617-4176 Please Print Name Last First Middle Initial Address Number and Street Name City State Zip Date of Birth Social Security Number This IDENTIFICATION worksheet is for the (Choose only one).

4 Owner Insured Beneficiary Premium Payer TO BE COMPLETED BY A CATHOLIC ORDER OF FORESTERS (COF) agent . This section must be completed by a COF agent after the agent has examined at least one document from the attached Acceptable IDENTIFICATION list. Each document's title, issuing authority, number, and expiration date (if applicable) must be recorded. Document Title Issuing Authority Number Expiration Date CERTIFICATION. I attest I have examined the document/s presented by the above-named individual and the document/s listed above appear to be genuine and relate to the named individual. Catholic Order of Foresters agent Date Signature Note: This form may be signed by a High Court Home Office employee if NO agent was involved.

5 IW-50 (4/07) 11-026 3 of 3.