primerica-death-claims-form.pdf

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Claim Instructions

Please review these instructions as you complete the enclosed claim form. If you need help, please contact your Representative or

call us, toll-free, at (888) 893-9858.

Who should complete the claim form?

• If you are the Beneficiary, complete and submit the claim form

• If there is more than one Beneficiary, each Beneficiary must complete their own claim form

• If the Beneficiary is a minor, incapacitated, or is unable to sign, the person who is empowered to act for the beneficiary

must complete and submit the claim form (examples: a guardian, conservator or power of attorney)

• If the Beneficiary is an estate or a trust, the executor, administrator or trustee must complete and submit the claim form

What documents do I need to provide?

• Copy of the beneficiary’s state or federal issued I.D.

- Examples: driver’s license, identification card or passport

• Certified copy of Insured’s death certificate with the cause and manner of death

• If the Beneficiary is a minor, incapacitated, or is unable to sign:

- Copy of the guardian’s, conservator’s or power of attorney’s state or federal issued I.D.

- Certified copy of the Letters of Guardianship, Conservatorship Appointment and/or Power of Attorney

• If the Beneficiary is an estate or a trust:

- Copy of the executor’s, administrator’s or trustee’s state or federal issued I.D.

- Certified copy of the Letters Testamentary, Letters of Administration or Trust Documents

• If any Primary beneficiary named in the policy is deceased, a copy of their death certificate

What else do I need to know?

• The Social Security number of the minor child or incapacitated beneficiary will be needed

• The tax identification number of the estate or trust will be needed

• All documents you send to us become a part of the claim file and will not be returned to you

How do I submit the claim?

• Please submit the completed and signed claim form with the documents listed above to:

Primerica Life Insurance Company

Attn: Claims Department

Executive Office: 1 Primerica Parkway

Duluth, GA 30099-0001

Payment methods and settlement options for claim proceeds:

For payments under $10,000, a check will be issued. For payments of $10,000 or more, you may choose to receive either

one check for the entire amount of the proceeds, one of the settlement options described in the policy, or you may chose

to establish Primerica Estate Account (“Account”) to which the proceeds (which remain in Primerica Life’s general account)

are credited. The Account is subject to the Terms and Conditions of the Primerica Estate Agreement on the reverse side of

these instructions.

Please refer to the policy contract and review the settlement options that may be available to you. These options provide

fixed interest rates (ranging from 0.75% to 3.5%) and may include (A) Installments for a fixed period; (B) Monthly installments

for a guaranteed minimum and thereafter, for life; (C) Proceeds held by Primerica Life and available for withdrawal; or, (D)

Installments of a selected amount until the proceeds are fully paid. If you choose to establish a Primerica Estate Account,

your settlement options, if any, will be preserved until the entire balance is withdrawn or the balance drops below the

minimum balance of $2,500.00.

Executive Office: 1 Primerica Parkway, Duluth, Georgia 30099-0001

(888) 893-9858

CLMIN

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Draft checks to withdraw funds from the Primerica Estate Account are processed through The Northern Trust Company, Chicago,

Illinois, and clear through ordinary banking channels. Funds in your Primerica Estate Account are held by and remain an asset of

Primerica Life until paid. If you or your bank have any questions, please call (800) 343-2551 or write to: Primerica Estate Account,

P.O. Box 92987, Chicago, Illinois 60675-2987.

Terms and Conditions

A. Proceeds and Deposits – This account credits proceeds from a Primerica Life Insurance Company policy payable due to the

death of the insured. Deposits cannot be made into the Primerica Estate Account by the beneficiary.

B. Interest – The Primerica Estate Account calculates and pays interest based, in part, on current market conditions. The variable

interest rate, which will never be less than .25%, is periodically determined by Primerica Life Insurance Company after review

of one month Treasury Bill interest rates. Primerica Life Insurance Company may derive income, in addition to any fees charged

on the Estate Account, from the total gains received on the investment of the balance of funds in the Estate Account. Interest

rates may change without notice. The current interest rate is shown on the monthly statement. Once credited to the Account,

payment represents full and final settlement of the claim and will include any applicable state interest or premium refund.

Interest is compounded daily and credited to your account on the statement date each month, increasing the annual yield that

you earn. The interest earned on your Primerica Estate Account is taxable; you should consult a tax advisor. Interest will be

available for withdrawal on the day after it has been credited.

C. The Safety of the Primerica Estate Account – Estate Account balances are held by and backed by the financial strength of

Primerica Life Insurance Company. The Estate Account balances remain with Primerica Life in its general account until your draft

check clears. The Primerica Estate Account is not a bank account or money market account and is not insured by the Federal

Deposit Insurance Corporation (FDIC). However, Estate Account balances are also protected by state guaranty funds, up to state

coverage limits, which vary by state but are generally $300,000.00. FOR FURTHER INFORMATION PLEASE CONTACT YOUR STATE

DEPARTMENT OF INSURANCE. You may also contact National Organization of Life and Health Insurance Guarantee Associations

(NOLHGA) to learn more about the coverage limitations applicable to your Estate Account at www.nolhga.com or (703) 481-5206.

D. Immediate Access to Your Money – You will receive a book of draft checks, which provides ready access to the funds credited

to your Primerica Estate Account once your claim has been approved. One draft check can be written to access the entire

proceeds at any time. Or, if you choose, you can write draft checks for $250 or more. The Primerica Estate Account is a draft

account–not a bank checking account. There are generally no delays in completing authorized transactions using these draft

checks. These draft checks cannot be used for electronic funds transfers (EFT) transactions. Retailers that scan checks

and debit account funds at the time of purchase may not accept the draft checks.

You must sign the claim form below as you would sign a check. For your protection, signature verification is performed

on all checks written on the Primerica Estate Account. Your signature on the Beneficiary’s Information page is used for

that verification.

With the Primerica Estate Account, you will receive:

• A Confirmation Certificate, showing the amount of life insurance proceeds available through your Account, your Account

number, the current interest rate, effective annual yield, and a Beneficiary Designation form;

• Your Primerica Estate Account Agreement spelling out the exact terms and conditions of your Primerica Estate Account in

an easy-to-read format;

• A book of draft checks giving you immediate access to your money.

The funds you don’t need right away are held by Primerica Life’s general account and continue to earn interest.

E. Monthly Statements – You will receive a statement of account each month by mail, showing withdrawals, interest credited,

and any other account activity. If you should need a copy of a draft check, please call (800) 343-2551 and a photocopy will be

forwarded to you. Any errors or omissions must be reported in writing to the above address no later than 15 days after you

receive your statement.

Primerica Estate Account Agreement

Executive Office: 1 Primerica Parkway, Duluth, Georgia 30099-0001

(888) 893-9858

EE9-A

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F. Minimum Claim and Automatic Closeout – You must be due a claim payment of $10,000 or more in order to establish a

Primerica Estate Account. You may withdraw part or all of the money at any time with no penalty or loss of interest. A minimum

balance of $2,500.00 is required to maintain the Primerica Estate Account. If the balance falls below $2,500.00 at any month

end after your account is established, your Primerica Estate account will be closed automatically. The balance in the account

will be sent to you, together with any interest due, promptly after the end of the following month.

G. Free Draft Check Services and Special Fees – With the Primerica Estate Account, you pay nothing to open the Account. There

are no fees for Account services – i.e. no monthly service charges and no charge for draft checks. The only charges you incur are

for special situations, such as:

1. Insufficient funds – $10.00 for each draft check presented for payment when there are insufficient funds available in your

account. A draft check that exceeds available funds in your account will not be paid.

2. Stop payment – $15.00 for each stop payment order.

H. Inactive Retained Asset Accounts – If no funds are withdrawn or no affirmative directive has been provided by you during

any continuous dormancy period under your state’s unclaimed property laws, your account will be considered inactive. We will

attempt to contact you at the address on record to allow you the option of keeping your Account or receiving the balance by

check. If we cannot contact you, your funds will be at risk of escheatment to the state.

I. Beneficiary Designation – We will enclose a change of beneficiary form for you to name a beneficiary to whom the balance of

the Primerica Estate Account will be paid in the event of your death. If no beneficiary is named, all available proceeds will be paid

to your estate. In the case of Company insolvency, a lengthy delay is possible before a beneficiary can get the proceeds from the

Primerica Estate Account.

J. Entire Agreement – This Agreement constitutes the entire Account contract between you and Primerica Life. Changes to

this Agreement may be made only in writing, signed by an authorized officer of Primerica Life. No provision can be waived or

changed by any other employee, representative or agent of Primerica Life. The rules and regulations concerning the use of the

Estate Account, however, are subject to change by the Northern Trust Company at any time upon 10 days written notice.

Primerica Life Insurance Company reserves the right to make changes in the terms and conditions of this account, including

selecting a different benchmark on which to base interest rates credited. In the event of changes, notice of the proposed changes

will be sent to you. You will have reasonable time to agree to these changes. Continuation of the account will affirm agreement to

those changes.

Please call if you have any questions related to the foregoing.

Scott Bramlett

Vice President, Claims Department

Primerica Life Insurance Company

Primerica Estate Account Agreement

Executive Office: 1 Primerica Parkway, Duluth, Georgia 30099-0001

(888) 893-9858

EE9-A-2

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Please Attach a Certified Death Certificate

1. Deceased’s Full Name ______________________________________________________________________________________________

2. Other Names

(including full name, maiden name, hyphenated name, nickname, derivative form of first and/or middle name, or any alias)

__________________________________________________________________________________________________________________

3. Policy Numbers ____________________________________________________________________________________________________

4. Deceased’s Birth Date (MM/DD/YYYY) ____________________________________

5. Residence of Deceased at Death

___________________________________________________________________________________________________________________

Street Address

___________________________________________________________________________________________________________________

City State Zip

6. Date of Death (MM/DD/YYYY) ____________________________________

7. Place of Death _____________________________________________________________________________________________________

8. Cause of Death _____________________________________________________________________________________________________

9. Relationship to Deceased ___________________________________________________________________________________________

10. If deceased has insurance with other companies, list names of companies and amounts below:

11. Marital Status of Deceased ____________________________________

12. Spouse’s Name _____________________________________________________________________________________________________

13. Children of Deceased _______________________________________________________________________________________________

______________________________________________________________________________________________________________________

The furnishing of this form or its acceptance by the Company shall not be construed as an admission of any liability on the part of the

Company, nor a waiver of any of the conditions of the insurance contract.

Name of Companies Amounts

Claim Form Statement

Executive Office: 1 Primerica Parkway, Duluth, Georgia 30099-0001

(888) 893-9858

PLA-880

Page 5 of 7 05.11.23

1. Beneficiary’s Full Name ___________________________________________________________________________________________

2. Date of Birth (MM/DD/YYYY) _______________________ 3. Social Security No. or Tax ID ___________________________________

Individual Beneficiary’s Social Security Number / Estate Tax ID Number / Trust Tax ID Number

4. Permanent Address ______________________________________________________________________________________________

(Number, Street, and Apt. or Suite No. – Do not use a P.O. Box or in care of address)

___________________________________________________________________________________________________________________

City State Zip

5. Mailing Address __________________________________________________________________________________________________

(if different than above)

___________________________________________________________________________________________________________________

City State Zip

6. Cell Phone ______________ _______________________ 7. Other Phone ______________ _______________________

Area Code Phone Number Area Code Phone Number

Please select your method of payment

Primerica Estate Account Check Settlement Option # __________________________________________________

(Refer to the Claim Instructions and the Policy)

Please be sure to review the payment method information found in the Claim Instructions on page 1 and the “Terms and

Conditions” of the Primerica Estate Account Agreement on page 2. Your signature below confirms acceptance of the

Primerica Estate Account Agreement if chosen above.

Under the penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number; and

2. I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified

by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of failure to report interest or

dividends, or (c) that the IRS has notified me that I am no longer subject to backup withholding; and

3. I am a U.S. person (including a U.S. resident alien).

Certification Instructions. — You must cross out item 2 if you have been notified by the IRS that you are currently subject to backup

withholding because you have failed to report all interest and dividends on your tax return.

Any person who knowingly and with intent to injure, defraud or deceive any insurance company, files a statement of claim

containing any false, incomplete, or misleading information may be guilty of a criminal act punishable under law. See the

“State Fraud Warnings” page for important state specific fraud warnings.

By signing below, I acknowledge I have read the applicable fraud warning on the “State Fraud Warnings” page and I certify

that all answers on this form are true and correct.

Name __________________________________________________ Signature X ________________________________________________

(Please Print) (See “Claim Instructions”)

Date (MM/DD/YYYY) ____________________________________

The furnishing of this form or its acceptance by the Company shall not be construed as an admission of any liability on the part of

the Company, nor a waiver of any of the conditions of the insurance contract.

PLA-880

Beneficiary Information

Executive Office: 1 Primerica Parkway, Duluth, Georgia 30099-0001

(888) 893-9858

PLA-880-2

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Some states require specific fraud warning language be

provided. Please read the fraud warning for the state

where you live and the state where the policy was issued,

if different.

Alabama — Any person who knowingly presents a false or

fraudulent claim for payment of a loss or benefit or who

knowingly presents false information in an application for

insurance is guilty of a crime and may be subject to restitution,

fines, or confinement in prison, or any combination thereof.

Alaska — A person who knowingly and with intent to injure,

defraud, or deceive an insurance company files 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, Louisiana, Rhode Island, West Virginia — Any

person who knowingly presents a false or fraudulent claim

for payment of a loss or benefit or knowingly presents false

information in an application for insurance is guilty of a crime

and may be subject to fines or confinement in prison.

California — For your protection California law requires the

following to appear on this form: Any person who knowingly

presents false or fraudulent information to obtain or amend

insurance coverage or to make a claim for the payment of

a loss is guilty of a crime and may be subject to fines and

confinement 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,

fines, 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 — Any person who knowingly, and with intent

to injure, defraud or deceive any insurer, files a statement

of claim containing any false, incomplete or misleading

information is guilty of a felony.

Washington D.C. — 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 fines. In addition, an insurer may deny

insurance benefits, 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 files a statement of claim or

an application containing any false, incomplete, or misleading

information is guilty of a felony of the third degree.

Idaho — Any person who knowingly, and with intent to defraud

or deceive any insurance company, files a statement of claim

containing any false, incomplete, or misleading information

is guilty of a felony.

Indiana — A person who knowingly and with intent to defraud

an insurer files a statement of claim containing any false,

incomplete, or misleading information commits a felony.

Kentucky — Any person who knowingly and with intent to

defraud any insurance company or other person files an

application for insurance 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.

Maine — It is a crime to knowingly provide false, incomplete

or misleading information to an insurance company for the

purpose of defrauding the company. Penalties may include

imprisonment, fines or a denial of insurance benefits.

Maryland — Any person who knowingly or willfully presents

a false or fraudulent claim for payment of a loss or benefit

or who knowingly or willfully presents false information in

an application for insurance is guilty of a crime and may be

subject to fines and confinement in prison.

Minnesota — A person who files a claim with intent to defraud

or helps commit a fraud against an insurer is guilty of a crime.

State Fraud Warnings

Executive Office: 1 Primerica Parkway, Duluth, Georgia 30099-0001

(888) 893-9858

PLA-880-5

Page 7 of 7 05.11.23

New Hampshire — Any person who, with a purpose to injure,

defraud, or deceive any insurance company, files 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 files a statement

of claim containing any false or misleading information is

subject to criminal and civil penalties.

New Mexico — Any person who knowingly presents a false or

fraudulent claim for payment of a loss or benefit or knowingly

presents false information in an application for insurance is

guilty of a crime and may be subject to civil fines and criminal

penalties.

Ohio — Any person who, with 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 is guilty of insurance fraud.

Oklahoma — WARNING: Any person who knowingly, and with

intent to injure, defraud or deceive any insurer, makes any

claim for the proceeds of an insurance policy containing

any false, incomplete or misleading information is guilty of

a felony.

Pennsylvania — 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 subjects such person to criminal and civil penalties.

Puerto Rico — Any person who knowingly and with the

intention of defrauding presents false information in an

insurance application, or presents, helps, or causes the

presentation of a fraudulent claim for the payment of a

loss or any other benefit, or presents more than one claim

for the same damage or loss, shall incur a felony and, upon

conviction, shall be sanctioned for each violation by a fine

of not less than five thousand dollars ($5,000) and not

more than ten thousand dollars ($10,000), or a fixed term of

imprisonment for three (3) years, or both penalties. Should

aggravating circumstances [be] present, the penalty thus

established may be increased to a maximum of five (5) years,

if extenuating circumstances are present, it may be reduced

to a minimum of two (2) years.

Texas — 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 fines and confinement in state prison.

Tennessee, Virginia, 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, fines and denial of

insurance benefits.

For all other states — Any person who knowingly and with

intent to injure, defraud or deceive any insurance company,

files a statement of claim containing any false, incomplete,

or misleading information may be guilty of a criminal act

punishable under law.

State Fraud Warnings

Executive Office: 1 Primerica Parkway, Duluth, Georgia 30099-0001

(888) 893-9858

PLA-880-6