This form is a Renunciation and Disclaimer of a Life Insurance Policy and/or Annuity Contract proceeds. Upon the death of the decedent, the beneficiary gained an interest in the proceeds of the decedent's policy and/or contract. Pursuant to the Indiana Code, Title 29, Chapter 2, the beneficiary has chosen to disclaim his/her interest in the proceeds. The renunciation will relate back to the date of death of the decedent and will serve as an irrevocable refusal to accept the proceeds. The form also contains a state specific acknowledgment and a certificate to verify delivery.