AARP Claim Form

Insurance Contract Number: Date of Death:

Name:

List all other names by which the deceased was known:

Cause of Death: Natural Accident Unknown Suicide Homicide Other

* Please attach copies of police and coroner's report and any relevant news articles.

Name: Sex: Male Female

Mailing Address: Home Phone No:

Business Phone No:

Social Security or Taxpayer Identification Number: Date of Birth:

Check if statement below applies:

I have been notified by the Internal Revenue Service that I am subject to back-up withholding as a result of failure to report all interest or dividends.

In what capacity are you making this claim?

Beneficiary Executor Trustee Assignee Other

Relationship to the Deceased: Spouse Child Grandchild Parent Other

You are automatically eligible for the Continued Interest Account if you are a named beneficiary and your proceeds are $5,000 or more. If no option is chosen, New York Life Insurance Company is required to pay the claim in a Lump Sum Payment. *Please note that CIA payments must be made to your physical address and cannot be made to P.O. Boxes.

Continued Interest Account (CIA) Lump Sum Payment (Payment by Check)

I certify that the Social Security or Taxpayer Identification Number and Back-up Withholding status information in Section 2 are correct. I also understand that my signature will be used for signature verification for my Continued Interest Account. I further certify that I am a U.S. person, including a U.S. resident alien (non-US person must complete form W8-BEN). In addition, I have read and understand the Fraud Statement that is applicable to the state in which I reside. New York Residents: Any person who knowingly and with intent to defraud any insurance company or other person files 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 five thousand dollars and the stated value of the claim for each such violation.

Please complete this section if all or any portion of the insurance coverage was issued within two years of the insured’s death.

Please list the insured’s family doctor as well as the names, addresses and telephone numbers of any other physicians, clinics and hospitals that may have treated the insured during the past five years.

Primary Care Physician Telephone Number

Physician or Hospital Name Telephone Number

Physician or Hospital Name Telephone Number

Medical Authorization:

I give my permission to release information concerning who died on to New York Life including its agents, attorneys, reinsurers and insurance support groups acting on their behalf. Information released may include records of medical advice, medical care, medical treatment of AIDS or AIDS-related diseases, mental illness, drug or alcohol abuse, other insurance coverage, financial and employment history. This information may be released by medical professionals or facilities, pharmacies, government offices, employers, insurance companies, insurance support groups, group policy holders or benefit plan administrators. When requesting information from any of the sources named above, a copy of this form is as good as the original. I am aware that any information obtained will be used to judge my claim. I understand that my claim will not be processed unless this authorization is completed and signed. Either I, or a person I choose, am entitled to receive a copy of this signed authorization. This authorization is valid from the date signed until the claim is resolved, except in those states, which allow for only a one-year limit.

I have the right to revoke this authorization at any time by notifying New York Life in writing at the address on this authorization. My revocation will not be effective to the extent New York Life or any other person already has disclosed or collected information or taken other action in reliance on this authorization. My revocation will also not be effective to the extent state law gives New York Life the right to contest a claim under the policy or the policy itself.

The information New York Life obtains based on this authorization may be subject to further disclosure. For example, New York Life may be required to provide it to an insurance regulatory or other government agency. In this case, the information may no longer be protected by the rules governing this authorization.

Return this Claim Form and a Certified Copy of the death certificate to:

New York Life Insurance Company/AARP Operations

P.O. Box 30713

Tampa, FL 33630-3713