Life Insurance Claimant’s Statement

1 Policy Number(s) _____ LCL01 03/14 Page 1 of 6 life Insurance claimant s Statement Policy number(s) Name of Deceased Other names by which the deceased may have been known (Such as maiden name, hyphenated name, nickname, derivative form of first and/or middle name or an alias)

2 Date of Birth Date of death Social Security Number_____ Cause of Death _____ Marital Status: Single Married Widow/Widower Separated Divorced Name of Spouse Beneficiary Name Address City, State, ZIP Social Security Number _____ Date of Birth Male Female / Your Relationship to Decedent Phone Number: Day ( ) Alternate ( ) Marital Status.

3 Single Married Widow/Widower Separated Divorced Trust/Estate Tax ID Date of Trust _____ (If Applicable) Are you a citizen of the United States of America? Yes No If No, list country _____ and attach a copy of the front and back of your Permanent Resident Visa (Green Card). Country of Birth (if other than the United States): _____ Beneficiary name has changed: Please complete only if current name is different from that listed on policy records.

4 The beneficiary new name is: _____ New Full Name (please print) _____ Previous Full Name (please print) Reason for change: ____ Marriage ____ Divorce ____ Adoption ____ Other (Explain) Please provide a copy of supporting documentation for name change; , marriage certificate, adoption certificate, social security card, divorce decree, naturalization verification, court order, or other documentation determined acceptable by Beneficial life Insurance Company.

5 Please call our Benefits Department at 1-800-283-8931 for assistance. Beneficiary Information One claim form per Beneficiary, please print clearly or type Policy Information 55 No. 300 West, Suite 375 Salt Lake City, Utah 84101 (801) 933-1100 (800) 233-7979 Policy Number(s) _____ LCL01 03/14 Page 2 of 6 When did Deceased first give indication of last illness? _____ If the policy is less than two years old, list the names and addresses of all physicians who attended the deceased and all hospitals or institutions where treated during the last illness (attach additional page if necessary include policy number).

6 Name Address Date Disease or Condition _____ _____ Settlement Options Cash Settlement* Other * For personal beneficiaries receiving $5,000 or more, the cash settlement option is the Beneficial Legacy Account. The Beneficial Legacy Account is an interest-bearing draft account in your name. You will receive a checkbook, and may immediately access all or a portion of the funds by writing a check against the account. **Legacy Accounts are not available to residents of Maryland or New Jersey.

7 If you have questions about the Beneficial Legacy Account, or if you would like more information about other settlement options ( , installment or life income options), please call us at 1-800-283-8931. Transfer all proceeds to an existing Beneficial contract: Existing contract #_____ is required. These options are available to all individual beneficiaries. Beneficial Financial Group Professional Agent Name: _____ Agent No: _____ Address: Phone #: _____ Fax #: _____ Would you like to deliver the proceeds?

8 Yes No Special Handling Instructions: _____ Policy Number(s) _____ LCL01 03/14 Page 3 of 6 Substitute W-9 Check this box if you have been notified by the Internal Revenue Service that you are subject to backup withholding on interest and dividends. 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.

9 The Internal Revenue Service does not require your consent to any provisions of this document other than the certification required to avoid backup withholding. Authorization and Signature The undersigned beneficiary hereby make(s) claim for life proceeds. The furnishing of this form, or any other forms supplemental to it, is not an admission that there was a life contract in force, nor a waiver of any rights or defenses of the Company. I/We certify, under penalty of perjury, that the information above is true, correct and complete to the best of my/our knowledge, and I/We have read the fraud notice and required statements associated with this Statement .

10 (If signing for another entity other than yourself include your title, see authorization and signature instructions on pages 4- 6) Beneficial accepts these and all other ancillary documents solely for own use in processing policies and claims. Our acceptance of such documents does not constitute acceptance of any related fiduciary duty, any duty to store or preserve such records, or any duty to return or produce copies or originals of such records. The death benefit option chosen is irrevocable and may not be changed once the claim has been processed.