Life Claims Claimant’s Statement

1 AmericanGeneralLifeandAccidentInsuranceC ompanyPO Box 30 580 0 NashvilleTN 37230-580 0 LifeClaimsClaimant sStatementPolic y Numbers _____,_____,__ _____, _____Informati on ab out the Dec eased :ClaimNumber_____1. Na me _____Dateof Death_____Fir stMid dle InitialLastMo .Da yYear2. OtherNa mes by which the Dec easedma y havebeenkno wn: _____3. Last Ad dress_____St ree t Numbe rStreetNameApt. Bo x # (if any)_____Ci tyStateZip4. MaritalStat us Married Sing le Widow/Wid ower Separated Divorced5. Da te of Birt h _____Placeof Bir th yYear6. Is pol icy less th an two yearsold? Yes No7. Is a claimbein g ma de fo r Accidental De ath Benefits? Yes NoIf Polic y Is Le ss Tha n Two Ye ar s Ol dple as e co mple te thi s se ct io n:Wh en did sympto ms of last il ln ess begin?

2 _____Wh en was a doc to r fir st consulted?_____Doc tor s Name :_____Address_____Phone#_____Was therea ho spi tal confinement? Yes NoName and ad dress of hosp ital: _____Phone#_____List nam es of doct ors /hospitalwheretre atmentwas receivedwit hin the past five years:Name :_____Add ress: _____Phone# _____Dat es of tr eat ment:_____Nat ure of Treatment:_____Name :_____Add ress: _____Phone# _____Dat es of tr eat ment:_____Nat ure of Treatment:_____If You Are Cla imi ng Any Ac ci de nta lDea th Be nefi tspl ea se compl ete this se ctio n:(In cl ude copiesof ava ila ble newspaperclippingsand/orpolicere port givingcircumstances)Ty pe of Acc id en t:_____Da te : _____Lo cation:_____De ta il s: _____Vehi cle Ac cide nt :Type of ve hicle:_____Nameof driver _____Hom ici de :Moti ve?

3 _____Arrestmade? Yes NoSuspects? (Givenames) _____Trial pending? Yes NoWi tn esses?(Givena me s, ad dresses,ph one numbers)_____Sui cid e:In ves ti gat ion com plet e? Yes NoWas a no te left? Yes No (If yes, sub mit copy)Wi tn esses?(Givesna me s, ad dressesand phonenumbers) _____AGL A1 80 A RE V0809 Pag e 1 Informati on ab out Yo u:1. You r Nam e(pleaseprint or type)_____Your date of birth_____Fir stMiddl e In iti alLast2. You r Pho ne Number(in casewe needto contactyou): Day _____Evening_____3. You r Mailin g Address_____Stree t Numbe rStreetNameApt. Bo x (if any)_____CityStateZip4. You r relat io nshipto th e Insur ed. You are the: Sp ouse Child Other_____Please Expl ain5. Ha ve yo u give n a funeralhom e an assignmen t to collectany amountdue underthis claim ?

4 Yes NoName of funer al ho me _____Phon e # _____Amount assigned:$ _____-------Pa ym ent of Pol ic y Pr oce eds -------If your insu ran ce benefitis $10,000 or more,you may electto havethe proceedspaid through a free, interest-bearin g accountin you r na me . Thi s acco un t, calledth e ConvenienceBen efit Account is a safe,secureplaceto keepyour proceedswhileyo u decide how tobest use them. A per sona l checkbook will be mailedto yo u onceyour claimhas may accessall or part of the moneysimplyby wr iti ng a ch eck fo r $250 .00 or more. Any amountth at remains in the accountwill co ntinueto earn interest. Bothyo ur prin cipalan d any interestyou earn are guarantee d by Amer ican General life and AccidentInsuranceCompany(AGLA).

5 The est ab lishm ent of a ConvenienceBe nefit Acc ount satisfiesAGLA s contractualobligationfor th e paymentof certaininsurancepr oce eds. Th e Con ven ie nce Ben efit Acco unt is not in suredby the FederalDepositInsuranceCorp orationor any federalagency. Account balances ar e the liab ilit y of AGLA,an d AGLA reser ves th e rig ht to reduceaccountbalancesfor any paymentmadeiner ror. If an initiallife insu ran ce be nefit is less than $10 ,000,AGLA will sendyou a checkfor the total benefitamo unt. Pl ease pa y the insu rance pr oceeds through th e Convenience Benefit you do n ot ch oose to take ad vant age of th e Convenience Be nefit Account, select one of the following choices: Pl ease pa y the insu rance pr oceeds by check.

6 Pl ease p ay t he insurance proceeds by means of a Settlement option permitted by the Policy (please refer to settlement optionsin t he p olicy and in dicate you r preference):If yo u do not se lec t on e o f the o ptio ns above for payment, t he proceeds will be paid in to the Convenience Benefit Account ifthe amo un t is $1 0,00 0 or mo re . Ot herwise, the p ro ceeds will be paid by e: Th e signatu re o n t his claimant s Statement will be used as your signature card for the Convenience Benefit ur Social Securit y N umber/Ta x Id entifi ca ti on Number: _____Unde r p enalt ie s of perjury, I certify that : number sho wn o n this form is my correct taxpayer identification number (or I am waitingfo r t he n um ber to be issued to me ), an d am not subject to backup withholding because.

7 (a)I am exempt fro m backup withholding,or (b)I ha ve not b een not ified b y the Internal Revenue Service that I am subject to backup withholding as a result of a f ailure to reportal l interest or d ividends, or (c )th e IRS has notified me that I am no lo nger subject to backup withholding, and am an person(i nc ludi ng an U .S. resident alien).Cer tifi catio n ins tr uc tio ns:You must cross out item 2 above if you have been notified by the IRS that you are currently subject tobac kup wit hho lding because you h ave f aile d t o r eport all interest and dividends on your tax return. The IRS does not require yourco nsen t t o a ny p ro visi ons of this d ocument other than the certification required to avoid backup withholding.

8 I el ect NOT to ha veFede ral In com e Tax withheld from t he TAXABLE PORTION of my distributio n. I el ect to haveFede ral Income Tax withheld fr om the TAXABLE PORTION of my distributio r Si gnat ur e: I agree t o cooperate with the Company in its investigation of this claim by providing assistance including, but not limitedto, com pleting, sig ning an d su bm it ting any questionnaire or authorization for m needed by the Company, in its sole opinion, to conductit s i a cknowledg e tha t, due to t he requirements of certain medical providers and others as well as the requirements of applicable law, theau thori za tion o f so meo ne o ther than myself may be required to a cquire medical or other records n ecessary for the Company to considermy cla im.

9 Po ten tially dela ying th e p rocessing of such u nd erstand t hat no in sur an ce agent of the Co mp any is authori zed to make any claim decision or any representation as to whether anycl ai m sh ould or will be pa Int ern al Revenue Service do es n ot re quire your consen t to any pro vision of this document other than the certificationsreq uir ed t o a vo id backup _____Bene fic iary s Si gn atu re P LEA SE SIG N AS YOU WOULD SIGN A CHECKDateAGL A1 80 A RE V0809 Pag e 2 The Cla im P roce ssIn o rd er to exp ed it e the pro cessing of your claim , it is importa nt that you submit a fully completed and signed claimant s Statementand a c ertified copy of the In sured s death certificate. The particular cir cumstances of your claim may require t he submission ofaddit ional infor mat ion.

10 Su ch as: Cl ai ms by Est at e- If th e e xecutor o r administrator of an estate is filing a claim , he or she must complete and sign the claimant sSt at ement an d su bmit a cop y of the appointment papers. Ben ef iciar y is a Minor - If a legal guardian of the child s estate has been appointed, he or she must sign the claimant sSt at ement an d su bmit a cop y of the guardianship pap ers. Powe r o f A tto rney fo r th e b ene ficiary- You must att ach a copy of the Power of Attorney authorization. Assi gn men t - If benefits have been assigned to a funeral home or a financing company, we require an assignment form(p ro vid ed b y t he assig nee) be submitt ed. The assignme nt form must inclu de the po licy nu mb er (s), t he dollar am ount you wishto assi gn an d t he signature of the ben yo u n eed assistance completing this form, please contact us toll-free at B P RE-N OTI CEInf orma tion rega rding your i nsur ab il ity will be treated as conf ide ntia l.