Variable Annuity Death Claim - EDGE › MerchantUploads... · Variable Annuity Death Claim Page 4...

SA2200POS.27 Rev. 9.16

American GeneralLife Insurance CompanyAddress mail to:Annuity Service Center

Regular Mail

P.O. Box 15570Amarillo, TX 79105-5570

Overnight Mail

1050 North Western StreetAmarillo, TX 79106-7011 1-800-445-7862

Variable Annuity Death Claim

Please read the following instructions carefully. Any omissions or missing information may cause a delay in the processing of your claim.

General Instructions1. This death claim form must be completed, signed and dated by the person or persons to whom the claim is payable (“claimant”).

One death claim form may be used by same claimant for multiple contracts. Please use a separate form for each claimant.

2. A certifi ed death certifi cate or other acceptable proof of death must be included with all claims.

3. Until the life company named above (“the Company”) receives an original certifi ed death certifi cate and this form, funds held in variable annuity contracts (and therefore the benefi t payable) may be subject to market gain or loss. If additional requirements become necessary, the death claim will be paid at the current account value when all required documents are received by us. In some cases, a one-time transfer to the fi xed account and/or cash management portfolios may be made in order to limit market exposure.

4. WE RECOMMEND THAT YOU CONSULT YOUR TAX PROFESSIONAL REGARDING THE TAX CONSEQUENCES OF THIS CLAIM.

Election Instructions

A SPOUSAL CLAIMANT may elect one of the four options listed below:

1. Spousal Continuation, which enables a spousal claimant to continue the contract in the spousal claimant’s name. This option

is only available for non-qualifi ed deferred annuities or IRAs where the spouse is the sole primary benefi ciary or only

remaining benefi ciary as of September 30th of the year following the year of the deceased’s death.

ALL CLAIMANTS (including spouses) may elect one of the following options:

2. Extended Legacy Program, which provides claimants the opportunity to defer the distribution of claim proceeds. Generally, there are two options available: (1) the claimant may begin annual required minimum distributions based on life expectancy no later than December 31 of the year following the deceased’s death or (2) all funds must be distributed no later than December 31 of the year containing the fi fth anniversary of the deceased’s death. These options refl ect the minimum distribution requirements; however, both options also allow the claimant to take distributions up to 100% of the remaining contract value sooner than required. One or both of the Extended Legacy Program options may not be available on all contracts.

3. Annuity Income Payments, which provide the claimant periodic income payments over an elected period of time. Some or all annuity options may not be available for non-natural claimants. Please contact our Annuity Service Center for more information.

4. Lump Sum Cash Distribution, which provides a one-time payment equal to 100% of the claimant’s proceeds.

Note for contracts issued as 403(b) TSA: This claim form may only be used for election of the Extended Legacy Program (number 2 above); for all other elections please use claim form number QP2220POS (available from our Annuity Service Center).

• To elect Spousal Continuation (Non-qualifi ed or IRA only), complete and return only Section 1 (pages 5-6). • To elect Extended Legacy, complete and return only Section 2 (pages 7-11)• To elect Annuity Income Payments, complete and return only Section 3 (pages 12-14)• To elect Lump Sum Cash Distribution, complete and return only Section 4 (pages 15-16)

SA2200POS.27

When A Claim Is Payable To:

An Individual Claimant or Claimants A Death Claim form must be completed by each claimant. If any claimant has predeceased the owner or annuitant, the claim payable may substantially change. Please notify us immediately and provide a certifi ed death certifi cate for the deceased claimant.

A Trust A Death Claim form must be completed by the current Trustee(s), and a Certifi cation of Trust (form SA2239COT) must be provided.

An Estate, or Executors or Administrators of an Estate A Death Claim form must be completed by the estate’s executor or administrator and a certifi ed, court-approved appointment must be furnished.

A Minor The Death Claim form must be completed by a guardian of the estate of the minor (not necessarily the parent). A certifi ed, court-approved appointment must be furnished unless the amount qualifi es for payment under your state’s Uniform Transfers to Minors Act.

Children or Members of a Class (to be used when Claimants have not been identifi ed by name) A notarized representation and indemnifi cation form must be furnished, giving the names of each person who qualifi es for the claim. (If any of the claimant(s) have predeceased the owner or annuitant, the claim payable may substantially change. Please notify us immediately and provide a certifi ed death certifi cate for the deceased claimant.) The representation and indemnifi cation form is available through the Company.

An Assignee (recipient of collateral assignment) A Death Claim form must be completed by the assignee (for fi nancial institutions, a qualifi ed officer must sign). Please note: Taxable income will be reportable to the estate of the deceased.

The following are samples of how various types of claimants should complete section “B” of the Claim Form:

Individual Claimant

Trust or Estate Claimant

Minor Claimant

Variable Annuity Death Claim of 16

Last Name: Smith First: Jane MI: R_____ Address: 123 Main St City Any Town State: CA Zip: 99999__ Phone (daytime): 999-333-5555 Relationship to Deceased: Spouse_______________________ Date of Birth: 01-01-1948 SSN or TIN Required: 999-99-9999___________

Last Name: Jane R. Smith, Trust/Estate First: John T. Smith, Trustee/Executor MI: __ _____ Address: 123 Main St. City: Any Town State: CA Zip:_99999__ Phone (daytime): 999-333-5555 _________ Relationship to Deceased: Trust/Estate_____________ Date of Birth: N/A SSN or TIN Required: 999-99-9999___________

Last Name: Jane R. Smith, Guardian FBO First: John T. Smith, Minor MI: ______ Address: 123 Main St City: Any Town State: CA Zip:_99999____ Phone (daytime): 999-3333-5555 Relationship to Deceased: Son____________________________ Date of Birth: 01-01-1998 SSN or TIN Required: 999-99-9999 (Minor’s SSN) _______

SA2200POS.27

Notice to Same-Sex Couples

For federal tax law purposes, under current IRS guidance (1) a same-sex marriage that was valid in the state or country it was entered into will be recognized by the IRS, regardless of the married couple’s place of domicile; and (2) although a state may recognize domestic partnerships or civil unions, the terms “spouse,” “husband and wife,” “husband,” and “wife” do not include individuals who have entered into a registered domestic partnership, civil union, or other similar formal relationship recognized under state law that is not denominated as a marriage under the laws of that state.

Fraud Warning

The following fraud warning applies to claims fi led in all states except the states noted below:

In some states we are required to advise you of the following: Any person who knowingly intends to defraud or facilitates a fraud against an insurer by submitting an application or fi ling a false claim, or makes an incomplete or deceptive statement of a material fact, may be guilty of insurance fraud.

Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefi t or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fi nes or confi nement in prison, or any combination thereof.

Alaska: A person who knowingly and with intent to injure, defraud or deceive an insurance company fi les a claim containing false, incomplete or misleading information may be prosecuted under state law.

Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

Arkansas, Rhode Island, Texas and West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefi t or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fi nes and confi nement in prison.

California: For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fi nes and confi nement in state prison.

Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company

for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fi nes, denial of

insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false,

incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to

defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported

to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Delaware, Idaho, Indiana and Oklahoma: WARNING - Any person who knowingly and with intent to injure, defraud or deceive any insurer, fi les a statement of claim containing any false, incomplete or misleading information is guilty of a felony.

District of Columbia, Maine, and Tennessee: WARNING - It is a crime to provide false or misleading information to an insurer

for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fi nes. In addition, an

insurer may deny insurance benefi ts if false information materially related to a claim was provided by the applicant.

Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer, fi les a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony in the third degree.

Kentucky, Pennsylvania and New Mexico: Any person who knowingly and with intent to defraud any insurance company or other person fi les an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Louisiana: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefi t or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fi nes and confi nement in prison.


SA2200POS.27


Fraud Warning continued

Maryland: Any person who knowingly OR willfully presents a false or fraudulent claim for payment of a loss or benefi t or who knowingly OR willfully presents false information in an application for insurance is guilty of a crime and may be subject to fi nes and confi nement in prison.

Minnesota: A person who fi les a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, fi les a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

New Jersey: Any person who knowingly fi les a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

New York: Any person who knowingly and with intent to defraud any insurance company or other person fi les an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed fi ve thousand dollars and the stated value of the claim for each such violation.

Ohio: Any persons who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or fi les a claim containing a false or deceptive statement is guilty of insurance fraud.

Oregon: Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) by submitting an application, or (2) by fi ling a claim containing a false statement as to any material fact, may be violating state law.

Virginia: ANY PERSON WHO, WITH THE INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT MAY HAVE VIOLATED THE STATE LAW.

Washington: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the

purpose of defrauding the company. Penalties include imprisonment, fi nes, and denial of insurance benefi ts.

SA2200POS.27

Variable Annuity Death Claim—Spousal Continuation of 16

1 Spousal Continuation - Available for non-qualifi ed annuities and IRAs only

Spousal Continuation enables a spousal claimant to continue the contract in the claimant’s name.

A. Deceased’s Information

Last Name _____________________________________________ First ________________________________________ MI _____

Address _________________________________________ City ____________________________ State _______ Zip __________

Date of Death ____________________________ Date of Birth ____________________________ SSN _______________________

B. Claimant’s (Your) Information



Phone (daytime) ______________________ Date of Birth ____________________________ SSN/TIN _______________________

C. Contract Information

Contract Number(s) __________________________________________________________________________________________

D. Spousal Continuation Election

❑By checking the box to the left, I request the contract continue in my name. I affirm I am the sole primary benefi ciary or only remaining benefi ciary as of September 30th of the year following the year of the deceased’s death. I affirm I was the spouse of the deceased at the time of the deceased’s death. I understand I will be the new owner and annuitant on the contract, and new benefi ciaries should be designated. If the contract is owned by a trust, you may be able to continue in the name of the trust. Please contact the Annuity Service Center and request form SA2200CON.

Federal tax law requires that for IRAs, a spouse continuing the contract must begin taking distributions upon attainment of age 70½.

Generally, the contract and its elected features, if any, remain the same. You are subject to the same fees, charges and expenses applicable to the original owner of the contract. Upon your continuation of the contract, we will contribute to the contract value an amount by which the death benefi t that would otherwise have been paid to the benefi ciary upon the death of the deceased exceeds the contract value as of the Spousal Continuation date (“Continuation Contribution”), if any. We calculate the Continuation Contribution as of the date of the deceased’s death. We will add the Continuation Contribution as of the date we receive both your written request to continue the contract and all required documentation, including a certifi ed death certifi cate (“Continuation Date”). Please note: A CONTINUATION CONTRIBUTION IS NOT AVAILABLE ON ALL PRODUCTS.

Your contract and the Continuation Contribution (collectively, “Contract Value”) will be invested according to your instructions. If we do not receive your investment allocation instructions, we will invest the Contract Value based on the previous allocation instructions we have on fi le. No portion of the Contract Value can be invested in the DCA fi xed accounts. If the previous allocation instructions included the DCA fi xed account options, we will invest the corresponding percentage of the Contract Value in the Cash Management portfolio pending further instruction by you. Purchase Payments made after the Continuation Date may be invested in the DCA fi xed accounts, if available. To the extent that you invest in the variable portfolios or Market Value Adjusted (MVA) fi xed accounts, you will be subject to investment risk as was the original owner.

Generally, you cannot change any contract provision; however, on the Continuation Date you may terminate the original owner’s selection of one of the following death benefi ts: Combination HV & Roll-up, EstatePlus or Seasons Estate Advantage. If you terminate the Combination HV & Roll-up death benefi t on the Continuation Date, the fee will no longer be charged and the death benefi t will become the Standard Death Benefi t (return of premium or contract value, whichever is higher). If the EstatePlus or Seasons Estate Advantage death benefi t is terminated or if you die after the Latest Annuity Date, no death benefi t will be payable. Your attained age on the Continuation Date and on the date of your death will be used in determining any future death benefi t under the contract. Note: May not apply to all contracts. Please review the prospectus/contract for additional details. To terminate a Combination HV & Roll-up, EstatePlus or Seasons Estate Advantage death benefi t check the “Terminate optional death benefi t” box below.

❑ Terminate optional death benefi t

Some death benefi ts may be terminated by the Company if you exceed the maximum age requirement as of the Continuation Date. If the Company terminates a death benefi t, fees associated with the death benefi t will no longer be charged and the death benefi t thereafter will be the contract value.

Generally, you cannot continue a living benefi t unless the original owner elected to cover two covered persons. You may be able to cancel the living benefi t under certain circumstances. Please refer to your contract and prospectus for more information regarding Spousal Continuation.

It is not necessary to return the original contract if Spousal Continuation is elected.

SA2200POS.27

Variable Annuity Death Claim—Spousal Continuation of 16

E. Investment Allocation Options (Please tell us how you would like to invest funds) select oneNote: If you do not select one of the following, we will default future investment allocations based on the most recent allocation instructions we have on fi le.

❑ Leave the funds as they are currently invested. OR

❑ Reallocate the funds as indicated below. Attach an additional sheet, if necessary. Note: Allocations must be expressed in whole percentages and add up to 100%.

Portfolio Name Portfolio Manager Percentage

Total: 100%

F. Future Investment Allocations (Please tell us how you would like to invest future purchase payments) select oneNote: If you do not select one of the following, we will default future investment allocations based on the most recent allocation instructions we have on fi le.

❑ Update my future allocations with respect to subsequent purchase payments to match the funds as they are currently invested. OR

❑ Update my future allocations with respect to subsequent purchase payments according to the instructions above in the table in Section E.

G. Current Automatic Programs

Automatic programs such as Dollar Cost Averaging (DCA), Systematic Withdrawal, Automatic Required Minimum Distribution, and

Automatic Asset Rebalancing will terminate unless you instruct us otherwise. Upon termination of the DCA program, any amounts

remaining in DCA Fixed Account Option(s) will be transferred to the DCA target allocation(s) for the program being terminated.

Note: automatic asset rebalancing will continue if it is a requirement of an optional living benefi t that remains in effect pursuant to your election of Spousal Continuation.

H. Benefi ciary Designation Change

Designate your new benefi ciary(ies) below. The benefi ciary(ies) will receive any amounts remaining in the contract at your death. If a Trust is designated as the benefi ciary, please be advised at the time of your death, we will require a Certifi cation of Trust (form SA2239COT). Please note: If no benefi ciary is designated, the contract benefi ciary will be deemed to be the estate of the

owner. If a benefi ciary predeceases you, we will split that amount among the remaining primary benefi ciaries. If no primary

benefi ciaries remain, we will pay the benefi t to the contingent benefi ciaries.

1.

Last Name ___________________________ First ______________________ Relationship ________________ Percent ________%


SSN or TIN ________________________________ Date of Birth ____________________________ ❑ Primary ❑ Contingent

Email ____________________________________ Home Phone __________________ Cell Phone __________________

2.





If additional benefi ciaries are being designated, please attach an additional sheet.

Please note: The above benefi ciary designations will become effective only after the Company acknowledges via written

confi rmation its receipt of your request.

I. Signature

I have read the foregoing disclosures and certify that all information provided on this form is complete and true.

Claimant Signature Date

Please note that as required by state laws and regulations, the Company may have to disclose your personal information, including information concerning the annuity contract and the claim payment, to government agencies, including but not limited to state departments of revenue.

Mail your completed form to the address shown at the top of page 1.

SA2200POS.27

Variable Annuity Death Claim—Extended Legacy Program of 16

2 Extended Legacy Program - Available for non-qualifi ed annuities, IRAs and 403(b) TSAs only

The Extended Legacy Program (“Program”) provides claimants the opportunity to defer the distribution of claim proceeds. There are two options offered under the Program. The fi rst option enables the claimant to defer taking a full distribution until December 31st of the year containing the fi fth anniversary of the deceased’s death, at which time any amounts remaining in the contract will be distributed. The second option enables the claimant to receive annual required minimum distributions, generally over the claimant’s life expectancy, beginning no later than December 31st of the year following the deceased’s death. Both options allow the claimant to take discretionary distributions of up to 100% of the remaining contract value at any time. Additional information regarding these options is provided below. One or both of the options offered under the Program may not be available on all contracts. Please contact our Annuity Service Center at (800) 445-7862 for information regarding availability and to request the Extended Legacy Program Guide and product prospectus which detail the fees, programs and investment options applicable to the Program.




Date of Death ____________________________ Date of Birth ____________________________ SSN _______________________


(Last, First, MI or Trust/Estate) __________________________________________________________________________________


Phone (daytime) ____________________________ Relationship to Deceased ____________________________________________

Date of Birth _____________________________________________ U.S. SSN/TIN ________________________________________

Note: If the benefi ciary is a trust, indicate the oldest trust benefi ciary’s date of birth.



D. Extended Legacy Program Election

❑ By checking the box to the left, I elect the Extended Legacy Program.

With your election of the Extended Legacy Program, you are entitled to certain programs and the waiver of certain fees. Certain other contractual provisions do not apply. The following outlines your rights and obligations.

Programs Available to You

• Dollar Cost Averaging, Systematic Withdrawal and Automatic Asset Rebalancing are optional programs available to you for as long as your Extended Legacy Program election remains active.

Investment Allocations

• Variable portfolios available to you under the Extended Legacy Program may differ from those that were available to the deceased. In addition, variable portfolios may have higher underlying fund fees, particularly 12b-1 fees. Please review the Extended Legacy Program Guide and/or product prospectus to determine the investment options available to you. You may invest in any investment option available to you.

• You may execute transfers among the investment options available to you.

• You are responsible for any market gain or loss associated with the performance of the investment options in which you invest.

Distributions

• Distributions to you will be withdrawn proportionately from all investment options in which you invest. If you would like to set up portfolio-specifi c withdrawals, please contact our Annuity Service Center.

• If an Extended Legacy option requiring annual required minimum distributions is elected in Section E, your distributions will be calculated and distributed under the Automatic Withdrawal Program in order to avoid possible adverse tax consequences. You may take additional withdrawals at any time at your discretion. If the Automatic Withdrawal Program is in place, any withdrawals made in excess of your required minimum distribution will discontinue the Automatic Withdrawal Program until the next year.

SA2200POS.27


D. Extended Legacy Program Election continued

Limitations

• The death benefi t provisions applicable to the deceased no longer apply. The total claim received by you under the Extended Legacy Program will be based on the current death claim payable at the time of this election adjusted for investment performance. Therefore, the actual amount of claim proceeds paid under the contract may be less than the current death claim amount. Upon your death, any amounts remaining in the contract will be distributed to your designated benefi ciary.

• You cannot make additional contributions to the contract.

• No living benefi ts are available under the Extended Legacy Program. Any living benefi ts that may have applied to the deceased will no longer apply.

• Automatic programs, including Dollar Cost Averaging (DCA), Systematic Withdrawal, Automatic Required Minimum Distribution, and Automatic Asset Rebalancing, which the deceased may have elected, will be terminated concurrent with this election. Upon termination of the DCA program, any amounts remaining in DCA Fixed Account Option(s) will be transferred to the DCA target allocation(s) for the program being terminated.

• During the administration of the Extended Legacy Program, the contract has no annuitant.

Fees and Charges

• You are not subject to any upfront or deferred sales charges on any partial or full withdrawal.

• The Extended Legacy Program has a Separate Account Charge that may be less than the mortality and expense fees charged to the deceased. Please review the Extended Legacy Program Guide and/or product prospectus for information regarding the fees and charges applicable to you.

• Market Value Adjustments (MVA) on any fi xed accounts in which the deceased was invested will be waived for the reallocation or withdrawal of funds made at the time of this election only.

E. Distribution Options

Please select either Non-qualifi ed (below) or IRA/403(b) TSA (next page).

Non-qualifi ed (select one)

Note: Claimants of non-qualifi ed contracts who elect to participate in the Extended Legacy Program will lose the benefi t of an exclusion ratio to be applied to annual distributions, which may result in higher taxable distributions initially, until all earnings under the contract have been distributed and a return of cost basis begins thereafter.

❑ By checking the box to the left, I elect to defer receiving a complete distribution from the contract until December 31st of the year containing the fi fth anniversary of the deceased’s date of death. Any balance remaining in the contract on December 1st of that year will automatically be distributed to me prior to December 31st. Payment will be sent to my then-current address of record. Please complete Sections F-K.

OR

❑ By checking the box to the left, I elect to begin receiving annual required minimum distributions based upon my life expectancy. Distributions may begin no sooner than January 1st of the year following the year of the deceased’s death and must begin no later than December 31st of that year. Please complete Sections F-K.

SA2200POS.27


E. Distribution Options continued

❑ IRA or 403(b) TSA (select one)

Note: The availability of certain options offered under the Extended Legacy Program is dependent on whether the deceased died before or after beginning required minimum distributions.

If Required Minimum Distributions HAD NOT Begun:

If there is no designated benefi ciary or, with the exception of certain trusts, the benefi ciary is a non-natural entity such as an estate, only the fi rst option listed below is available. For certain trusts that meet specifi c IRS criteria, the fi rst two options listed below are available. If a trust elects the second option, distributions will be based upon the life expectancy of the eldest trust benefi ciary.Select one:

❑ By checking the box to the left, I elect to defer receiving a complete distribution from the contract until December 31st of the year containing the fi fth anniversary of the deceased’s date of death. Any balance remaining in the contract on December 1st of that year will automatically be distributed to me prior to December 31st. Payment will be sent to my then-current address of record. Please complete Sections F-K.

OR

❑ By checking the box to the left, I elect to begin receiving annual required minimum distributions based upon my life expectancy. Distributions may begin no sooner than January 1st of the year following the year of the deceased’s death and must begin no later than December 31st of that year. Please complete Sections F-K.

OR

❑ (Available for Spousal Claimant Only) By checking the box to the left, I elect to defer beginning annual required minimum distributions until December 31st of the calendar year in which the deceased would have attained the age of 70½. When annual required minimum distributions do begin, they will be based upon my life expectancy at that time. Please complete Sections F-K.

If Required Minimum Distributions HAD Begun:

If there is no designated benefi ciary or, with the exception of certain trusts, the benefi ciary is a non-natural entity such as an estate, only the fi rst option listed below is available. For certain trusts that meet specifi c IRS criteria, both options listed below are available. If a trust elects the second option, distributions will be based upon the life expectancy of the eldest trust benefi ciary.

Select one:

❑ By checking the box to the left, I elect to continue receiving annual required minimum distributions over the deceased’s remaining life expectancy as of the year of the deceased’s death. Please complete Sections F-K.

OR

❑ By checking the box to the left, I elect to begin receiving annual required minimum distributions based upon my life expectancy. Distributions may begin no sooner than January 1st of the year following the year of the deceased’s death and must begin no later than December 31st of that year. Please complete Sections F-K. Note: If the deceased had not taken the required minimum distribution for the year in which he/she died, that distribution, calculated based on the deceased’s life expectancy, must be taken prior to December 31st of the year of his/her death. Please include a letter of instruction requesting distribution of the deceased’s fi nal required minimum distribution with this death claim form.

Note: If you would like to receive an immediate distribution concurrent with your election or would like to receive distributions that exceed your annual required minimum distribution, please contact our Annuity Service Center for a Financial Authorization Form and submit it along with this form.

F. Frequency

Select distribution frequency: ❑ Monthly ❑ Quarterly ❑ Semiannually ❑ Annually

I would like my fi rst withdrawal to begin on: MO DAY YR , no sooner than January 1st of the year following the year of the deceased’s death.

SA2200POS.27


G. Tax Withholding

Notice and Tax Withholding Election for Extended Legacy Program — The taxable portion of withdrawals will be subject to 10% federal tax withholding unless you elect not to have withholding apply. You may also elect to have a percentage withheld in addition to the 10% withholding amount by checking the second box below and fi lling in the total percentage amount. Your distribution may also be subject to state withholding requirements. You may be subject to a 5% administrative default rate when state withholding is requested and no withholding amount is designated. A spousal benefi ciary requesting a distribution from a contract issued pursuant to a 403(b) retirement plan in excess of the required distribution amount is subject to mandatory 20% federal tax withholding.

Your tax withholding election below will remain in effect and apply to all future income payments you receive under this contract until you change or revoke it. To change your withholding election at any time, contract our Annuity Service Center.

If you elect not to have withholding apply or if you do not have enough federal income tax withheld, you are liable for payment of federal income tax on the taxable portion of your withdrawals. You also may be subject to tax penalties under the estimated tax payment rules if your payments or estimated tax and withholding, if any, are not adequate. Please note: When federal withholding is selected, the appropriate mandatory state withholding will apply.

Your state of residence may require that your state income tax withholding election be provided to us on a specifi c state form. If this is the case in your state, your state income tax withholding will not begin until after your state withholding election is received by our Annuity Service Center on the required state form. If you are a resident of CA or VT and your distribution is subject to mandatory federal withholding or you have elected state withholding, the state withholding will be a percentage of the federal withholding.

Select one:

❑ Do not withhold federal income tax

❑ Withhold a specifi c percentage for federal income tax of % (max 50%) and state income tax of % (max 50%)

❑ Withhold a specifi c dollar amount for federal income tax $ and state income tax $

H. Delivery Options

Select one:

❑ Electronic Fund Transfer (EFT) - direct deposit to your bank account. Please complete the information below and

attach a voided check (deposit slips and starter checks will not be accepted).

Account Holder’s Last Name _______________________________________ First ________________________________ MI _____

Financial Institution Name ___________________________________________________________ Type: ❑ Checking ❑ Savings*

Routing Number _____________________________________ Account Number __________________________________________

Allow 10 business days to set up the EFT. Your fi rst withdrawal may be a check sent to the address of record. Once EFT is set up, please allow two business days from each withdrawal date for the payment to be credited to your bank account.

*If a voided check is not available, please include a letter on bank letterhead confi rming your savings account information.❑ (Default) Mail to address as stated on page 7, Section B “Claimant’s Information”

I. Investment Allocation Options

Please review the Extended Legacy Program Guide and/or product prospectus, to determine the investment options available

to you.

Please tell us how you would like to invest funds, as indicated below. Attach an additional sheet, if necessary.

Note: This section must be completed; no default election applies. Allocations must be expressed in whole percentages and add up to 100%.


Total: 100%

SA2200POS.27

J. Benefi ciary Designation

Please designate your new benefi ciary(ies) below. The benefi ciary(ies) will receive any amounts remaining in the contract upon your death. If a Trust is designated as the benefi ciary, please be advised at the time of your death, we will require a Certifi cation of Trust (form SA2239COT). Please note: If no benefi ciary is designated, the contract benefi ciary will be deemed to be the claimant’s

estate, i.e., the individual electing Extended Legacy. If a benefi ciary predeceases you, we will split that amount among the

remaining primary benefi ciaries. If no primary benefi ciaries remain, we will pay the benefi t to the contingent benefi ciaries.1.





2.








K. Signature

I have read and understood the parameters of the Extended Legacy Program, reviewed and accept the fees, programs and investment options available to me, as disclosed in this section, in the Extended Legacy Program Guide and in the product prospectus, and certify that all information provided on this form is complete and true.

Claimant’s Signature Date _________


Mail your completed form to:

Annuity Service Center Regular Mail


Overnight Mail

1050 North Western StreetAmarillo, TX 79106-7011


SA2200POS.27

Variable Annuity Death Claim—Annuity Income Payments of 16

3 Annuity Income Payments

Annuity Income Payments provide the claimant periodic income payments over the elected period of time. Some or all income options may not be available to non-natural claimants.


Last Name _______________________________________ First _____________ MI __________

Address ___________________________________ City _____________________________ State _________ Zip _____________

Date of Death ___________________________ Date of Birth ___________________________ SSN _________________________


(Last, First, MI or Trust/Estate) ___________________________________________________________________________________

Address ___________________________________ City _____________________________ State _________ Zip _____________

Phone (daytime) __________________________________ Relationship to Deceased ______________________________________

Date of Birth _________________________________________ U.S. SSN/TIN ____________________________________________



D. Annuitization Income Options

❑ By checking the box to the left, I elect the Annuitization Income Option. It may take up to 30 days to receive your fi rst payment after receipt of your election in good order.

Note: If the contract was in the income payout phase prior to the deceased’s death, please complete Sections F-J.

Please tell us how you would like to receive income payments

Select one:

❑ INCOME FOR A SPECIFIED PERIOD (5-30 YEARS GUARANTEED): Payments will be made for a specifi ed period. If your death occurs during this period, the remaining payments will continue to your designated benefi ciary until the specifi ed period has expired. The specifi ed guaranteed period may not exceed your life expectancy.

Specify the number of years: (5-30) _____________

❑ LIFE INCOME ANNUITY: Payments will be made for your lifetime. Upon your death, payments stop; there are no further provisions for return of proceeds or payment continuation after your death.

❑ LIFE INCOME WITH 10 OR 20 YEARS GUARANTEED: Payments will be made for the longer of the specifi ed period or your lifetime. If your death occurs during the specifi ed guaranteed period, payments will continue to your designated benefi ciary for the balance of the specifi ed period.

Specify the number of years: ❑ 10 Years ❑ 20 Years

For life income options, a certifi ed birth certifi cate of the claimant must be submitted with this form.

PLEASE NOTE: The life income option offers higher income payments than income options with a guaranteed period, but does not guarantee a minimum number of payments; payments stop upon your death.

E. Frequency

Select payment frequency (Payments for ICAP and American Pathway contracts are only available on a monthly basis)

❑ Monthly ❑ Quarterly ❑ Semiannually ❑ Annually

SA2200POS.27


F. Tax Withholding Elections

Notice and Tax Withholding Election for Annuitization Income Option — The taxable portion of your periodic income payments will be subject to federal tax withholding unless you elect below not to have withholding apply. Withholding will treat each payment as a payment of wages. You may elect not to have tax withheld from your income payments by checking the fi rst box below, signing and dating this form and returning it to us. (However, we must have your correct Social Security number in order for you to opt out of withholding.)

If you do not opt out of federal withholding below, federal income tax will be withheld from your income payments using IRS wage withholding tables, based on the marital status and number of withholding allowances you have claimed below. If you do not elect a marital status and number of withholding allowances, we are required to withhold tax by treating you as a married individual claiming three (3) withholding allowances until you fi le an election to request withholding on a different basis. However, if we do not have your correct Social Security number, we must withhold tax by treating you as a single individual claiming (0) withholding. You may also elect, by fi lling in the amount below, to have a fl at dollar amount withheld in addition to the amount otherwise required to be withheld.

Your tax withholding election will remain in effect and apply to all future income payments you receive under this contract until you change or revoke it.

If you elect not to have withholding apply or if you do not have enough federal income tax withheld, you are liable for payments for federal income tax on the taxable portion of your income payments. You also may be subject to tax penalties under the estimated tax payment rules if your payments of estimated tax and withholding, if any, are not adequate. Please note: When federal withholding is elected, the appropriate mandatory state withholding will apply. If you are a resident of CA or VT and your distribution is subject to mandatory federal withholding or you have elected state withholding, the state withholding will be a percentage of the federal withholding.

Select one:

❑ I do not want to have federal income tax withheld from my periodic income payments.

❑ I want federal income taxes withheld as indicated below. (Unless you elect otherwise below, we are required to treat you as a married person, claiming three (3) withholding allowances.)

Withhold taxes based on:

(Enter number) Number of withholding allowances

Marital Status (check one):

❑ Single ❑ Married ❑ Married, but withhold at a higher single rate

I want an additional amount withheld of $ (please indicate the dollar amount).

G. Delivery Options (select one)

❑ Electronic Fund Transfer (EFT) - direct deposit to your bank account. Please complete the information below and attach a

voided check (deposit slips and starter checks will not be accepted).

Account Holder’s Last Name First MI

Financial Institution Name Type: ❑ Checking ❑ Savings*

Routing Number Account Number

Please allow 10 business days to set up the EFT. Your fi rst withdrawal may be a check sent to the address of record. Once EFT is set up, please allow two business days from each withdrawal date for the payment to be credited to your bank account.

*If a voided check is not available, please include a letter on bank letterhead confi rming your savings account information.

❑ (Default) Mail to address as stated on page 12, Section B “Claimant’s Information”

SA2200POS.27


H. Investment Allocation Options

Please tell us how you would like funds invested. Note: Allocations must be expressed in whole percentages and add up to 100%. Choose variable, fi xed, or a combination below

❑ Variable — if this option is chosen, a specifi ed number of units will be sold in the frequency previously indicated; therefore, the amount of the payments will fl uctuate based upon the investment option(s) selected and market conditions. Once annuitized, transfers can only be made to different variable subaccounts and are processed, upon your direction, on the fi rst business day of the next month. If no portfolio is specifi ed below, the account will retain the current investment options. Attach an additional sheet, if necessary.


Total of variable funds %

❑ Fixed — if this option is chosen, the percentage of funds elected will be transferred into a general account and each payment will generally be the same dollar amount. Once the fi xed option has been chosen, funds cannot be transferred back into the variable subaccounts. Please see your prospectus or Financial Advisor for additional information.

Total of fi xed Funds %

Total 100%

I. Benefi ciary Designation Change

Designate your new benefi ciary(ies) below. The benefi ciary(ies) will receive any amounts remaining in the contract upon your death. If a Trust is designated as the benefi ciary, please be advised at the time of your death, we will require a Certifi cation of Trust (form SA2239COT). Please note: If no benefi ciary is designated, the contract benefi ciary will be deemed to be the payee’s estate, i.e.,

the individual who has elected annuitization. If a benefi ciary predeceases you, we will split that amount among the remaining

primary benefi ciaries. If no primary benefi ciaries remain, we will pay the benefi t to the contingent benefi ciaries.

1.





2.








J. Signature


Claimant’s Signature Date


Mail your completed form to the address shown at the top of page 1.

SA2200POS.27

Variable Annuity Death Claim—Lump Sum Cash Distribution of 16

4 Lump Sum Cash Distribution


Last Name ________________________________________ First ______________________________________ MI ____________

Address __________________________________ City ______________________________ State ________ Zip ______________

Date of Death ____________________________ Date of Birth ____________________________ SSN ________________________


(Last, First, MI or Trust/Estate) ___________________________________________________________________________________


Phone (daytime) ____________________________ Relationship to Deceased ____________________________________________

Date of Birth __________________________________ U.S. SSN/TIN___________________________________________________


Contract Number(s) _________________________________________________________________________________________

D. Lump Sum Cash Distribution and Tax Withholding Elections

❑ By checking the box to the left, I elect a lump sum cash distribution.

Notice and Tax Withholding Election — The taxable portion of withdrawals will be subject to 10% federal tax withholding unless you elect not to have withholding apply. You may also elect to have a percentage withheld in addition to the 10% withholding amount by checking the second box below and fi lling in the total percentage amount. Your distribution may also be subject to state withholding requirements. You may be subject to a 5% administrative default rate when state withholding is requested and no withholding amount is designated. A spousal benefi ciary requesting a distribution from a contract issued pursuant to a 403(b) retirement plan in excess of the required distribution amount is subject to mandatory 20% federal tax withholding.

If you elect not to have withholding apply or if you do not have enough federal income tax withheld, you are liable for payment of federal income tax on the taxable portion of your withdrawals. You also may be subject to tax penalties under the estimated tax payment rules if your payments or estimated tax and withholding, if any, are not adequate. Please note: When federal withholding is selected, the appropriate mandatory state withholding will apply.

Your state of residence may require that your state income tax withholding election be provided to us on a specifi c state form. If this is the case in your state, your state income tax withholding will not begin until after your state withholding election is received by our Annuity Service Center on the required state form. If you are a resident of CA or VT and your distribution is subject to mandatory federal withholding or you have elected state withholding, the state withholding will be a percentage of the federal withholding.

Select one:

❑ Do not withhold federal income tax

❑ Withhold a specifi c percentage for federal income tax of % (max 50%) and state income tax of % (max 50%)

❑ Withhold a specifi c dollar amount for federal income tax of $ and state income tax of $

E. Delivery

All lump sum distributions will be mailed in the form of a physical check.

❑ (Default) Mail to address as stated on page 15, Section B “Claimant’s Information”

❑ Please mail my Lump Sum Cash Distribution check to my fi nancial institution as indicated below.

Financial Institution Name ______________________________________________________________________________________


Account Number ______________________________________________________________________________________________

Contact Name ____________________________________________ Contact Phone ______________________________________

SA2200POS.27

Variable Annuity Death Claim—Lump Sum Cash Distribution of 16

F. Signature


Under penalty of perjury, I certify: (1) that the Social Security number (SSN) or taxpayer identifi cation number (TIN) is correct as it appears on the claims form; and (2) that I am not subject to backup withholding under section 3406(a)(1)(C) of the Internal Revenue Code; and (3) I am a U.S. person (including U.S. resident alien); and (4) The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct (enter exemption from FATCA reporting code, if applicable: _______________).

The Internal Revenue Service does not require your consent to any provision of this document other than the certifi cations

required to avoid backup withholding.

Claimant’s Signature_____________________________________________________ Date _________________________________

G. Signature Guarantee

If the check amount exceeds $500,000, this request must be signature-guaranteed below. A signature guarantee may be

obtained at a bank or brokerage fi rm.

Attach Seal Here

Signature Date:


Mail your completed form to:

Annuity Service Center Regular Mail


Overnight Mail

1050 North Western StreetAmarillo, TX 79106-7011

PRIVACY NOTICE Rev. 3/2016

FACTSWHAT DO AMERICAN GENERAL LIFE INSURANCE COMPANY (AGL) AND THEUNITED STATES LIFE INSURANCE COMPANY IN THE CITY OF NEW YORK (US Life)DO WITH YOUR PERSONAL INFORMATION?

Why?Financial companies choose how they share your personal information. Federal law gives consumers theright to limit some but not all sharing. Federal law also requires us to tell you how we collect, share, andprotect your personal information. Please read this notice carefully to understand what we do.

What?

The types of personal information we collect and share depend on the product or service you have with us.This information can include:

• Social Security number and Medical Information• Income and Credit History• Payment History and Employment Information

When you are no longer our customer, we continue to share your information as described in this notice.

How?All financial companies need to share customers’ personal information to run their everyday business. Inthe section below, we list the reasons financial companies can share their customers’ personal information;the reasons AGL and US Life choose to share; and whether you can limit this sharing.

Reasons we can share your personal information Do AGL & US Lifeshare?

Can you limit thissharing?

For our everyday business purposes — such as to process your transactions,maintain your account(s), respond to court orders and legal investigations,conduct research including data analytics, or report to credit bureaus. Yes No

For our marketing purposes — to offer our products and services to you Yes No

For joint marketing with other financial companies Yes No

For our affiliates’ everyday business purposes — information about yourtransactions and experiences Yes No

For our affiliates’ everyday business purposes — information about yourcreditworthiness No We don’t share

For nonaffiliates to market to you No We don’t share

Questions? For AGL and US Life variable or index annuity contracts, call 1-800-445-7862, or send a secure messagevia our website at www.aig.com/asc/eservice or write to us at: P. O. Box 15570, Amarillo, TX 79105-5570.

For AGL and US Life variable universal life insurance policies, call 1-800-340-2765 or write to us at:VUL Administration, P. O. Box 305600, Nashville, TN 37230-5600.

For AGL and US Life Corporate Markets Group or High Net Worth life policies or annuity contracts, call1-888-222-4943 (AGL), 1-877-883-6596 (US Life) or 1-800-871-4536 (High Net Worth) or write to us at:Affluent and Corporate Markets Group, 2929 Allen Parkway - A35-50, Houston, TX 77019.

For AGL and US Life single premium immediate variable annuity contracts, call 1-877-299-1724, emailus at: [email protected] or write to us at: Group Annuity Admin Department, 405 King Street,4th Floor, Wilmington, DE 19801.

Rev. 3/2016Page 2

Who we are

Who is providing this notice? American General Life Insurance Company and The United States Life InsuranceCompany in the City of New York.

What we do

How do AGL & US Life protectmy personal information?

To protect your personal information from unauthorized access and use, we usesecurity measures that comply with federal law. These measures include computersafeguards and secured files and buildings. We restrict access to employees,representatives, agents, or selected third parties who have been trained to handlenonpublic personal information.

How do AGL & US Life collect We collect your personal information, for example, when youmy personal information? • Open an account or give us your contact information

• Provide account information or make a wire transfer• Deposit money or close/surrender an account

We also collect your personal information from others, such as credit bureaus,affiliates, or other companies.

Why can’t I limit all sharing? Federal law gives you the right to limit only• sharing for affiliates’ everyday business purposes — information about yourcreditworthiness

• affiliates from using your information to market to you• sharing for nonaffiliates to market to you

State laws may give you additional rights to limit sharing. See below for more on yourrights under state law.

Definitions

Affiliates Companies related by common ownership or control. They can be financial and non-financial companies.

• Our affiliates include the member companies of American International Group, Inc.

Nonaffiliates Companies not related by common ownership or control. They can be financial andnonfinancial companies.

• AGL & US Life do not share with nonaffiliates so they can market to you.

Joint Marketing A formal agreement between nonaffiliated financial companies that together marketfinancial products or services to you.

• Our joint marketing partners include companies with which we jointly offerinsurance products, such as a bank.

Other important information

You have the right to see and, if necessary, correct personal data. This requires a written request, both to see your personaldata and to request correction. We do not have to change our records if we do not agree with your correction, but we willplace your statement in our file. If you would like a more detailed description of our information practices and your rights,please write us at the addresses indicated on the first page.

For Vermont Residents only. We will not disclose information about your creditworthiness to our affiliates and will notdisclose your personal information, financial information, credit report, or health information to nonaffiliated third parties tomarket to you, other than as permitted by Vermont law, unless you authorize us to make those disclosures. Additionalinformation concerning our privacy policies can be found using the contact information above for Questions.

For California Residents only. We will not share information we collect about you with nonaffiliated third parties, exceptas permitted by California law, such as to process your transactions or to maintain your account.

For Nevada Residents only. We are providing this notice pursuant to state law. You may be placed on our internal Do NotCall List by calling the numbers referenced in the Questions section. Nevada law requires that we also provide you with thefollowing contact information: Bureau of Consumer Protection, Office of the Nevada Attorney General, 555 E. WashingtonSt., Suite 3900, Las Vegas, NV 89101; Phone number: 702-486-3132; email: [email protected]. You may contact ourcustomer service department by using the contact information referenced in the Questions section.

Variable Annuity Death Claim - EDGE › MerchantUploads... · Variable Annuity Death Claim Page 4...

Documents

Transcript of Variable Annuity Death Claim - EDGE › MerchantUploads... · Variable Annuity Death Claim Page 4...