Beneficiary Statement Template

Beneficiary Statement Template and Agreement

THIS BENEFICIARY STATEMENT AND AGREEMENT is made as of the date of signature below by and between the Beneficiary and the Payor/Administrator identified herein.

WHEREAS

WHEREAS, Decedent Name: died on (the "Decedent");

WHEREAS, the Decedent was the named owner or insured under the account/policy maintained with Institution Name: , Account/Policy Number: , described as with an approximate value of $.

WHEREAS, the undersigned Beneficiary asserts a right to payment or transfer of the proceeds or assets described above and provides the following statement and certifications to induce the Payor/Administrator to recognize and effect the transfer or payment.

Beneficiary Information

Certification and Representations

I/We, Beneficiary Name: , hereby certify under penalty of perjury that:

1. The foregoing information is true, correct and complete to the best of my/our knowledge and belief.
2. I/We am/are the lawful Beneficiary entitled to receive payment or transfer of the described proceeds or property and no other person has a superior claim.
3. I/We will indemnify and hold harmless the Payor/Administrator for any liability resulting from reliance on this statement and any supporting documents provided in good faith.

Documents Submitted

The Beneficiary has provided the following documents (check all that apply):

Scope of Services

The Payor/Administrator agrees to take the following actions upon receipt and verification of this Beneficiary Statement and the required supporting documentation:

Payment Terms (if services or fees apply)

Fee Amount: $   Payment Schedule:

Late Fee: will accrue on unpaid amounts measured from the payment due date.

Term and Termination

This Agreement is effective as of the Effective Date:

Termination Date (if applicable): .

Either party may terminate this Agreement upon written notice delivered at least days prior to the intended termination date, provided that termination will not relieve either party of obligations accrued prior to termination.

Confidentiality

The parties acknowledge that the information provided in this Statement and any documents submitted in support are confidential and will be used solely for the purpose of effecting the payment or transfer and for related administrative purposes. The Payor/Administrator shall not disclose such information except as required by law or to its legal and financial advisors who have a need to know and who are bound by confidentiality obligations.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the state of , without regard to conflict of law principles.

Entire Agreement

This document, together with any attachments and documents expressly incorporated herein, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous communications, representations, or agreements, whether oral or written.

Indemnity and Acknowledgement

The Beneficiary agrees to indemnify and hold harmless the Payor/Administrator from any claims, losses, liabilities, costs or expenses (including reasonable attorneys' fees) arising out of the representations made herein or the failure to disclose information material to the distribution of proceeds.

Acknowledgement of Receipt

The Payor/Administrator acknowledges receipt of the information and documents listed above and will take reasonable steps to process the claim in accordance with internal procedures and applicable law. The Payor/Administrator may request additional documentation if necessary.

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