Get Qualified Claimant's Statement

Claimant Statement Form—Income Annuity. Use this form to complete the settlement of your inherited income annuity contract. If you need more room for information or signatures, make a copy of the relevant page.

This form is used to collect information relating to the payment of death benefits. The information provided will be used to determine entitlement to death benefits. Persons are not required to respond to the collection of information unless it displays a currently valid OMB Control Number.

Claimant Statement Form—Term Life Insurance. Use this form to complete the settlement of your inherited term life insurance policy. If you need more room for information or signatures, use a copy of the relevant page.

When you purchase an annuity, you receive these statements either annually (if you own a fixed annuity) or quarterly (if you own a variable or fixed-indexed annuity). These quarterly statements show the growth or loss of your annuity value based on the investment subaccounts that are the basis for growth or loss.

Capacity is the legal authority that entitles you to claim proceeds. If you are claiming on your own behalf, you are an “individual claimant” and should indicate your capacity as Individual. Do not use any other “title” unless you are actually claiming in that capacity.

If I complete the form I received in the mail, how long will it take to get a check? It may take up to eight weeks once all required documentation is received. However, if you are the beneficiary claiming funds, it may take longer and additional documentation may be requested at a later date.

The statement will have an overview of the contract terms, like the names of the annuity owner and annuitant, if not the same person. This section also contains specific details of the annuity contract, including the product type, tax qualification status and effective date.

Who is the “Claimant”? A claimant is the person or entity claiming death proceeds under a contract. Each beneficiary must complete a separate annuity claim form.