HOW TO FILE A CLAIMPlease read the instructions on the claim form carefully.The form must be completed & faxed to 888-232-9835 before claim can be paid.Please call Customer Service with any questions at 1-800-773-6333.

~' 20c)()Wadr.Harnpton Blvd.

~ ASSURANT Solutions' ~~.:iJ~~29602-9061(800) 77l.clllPlease fax completed form to (888) 232~9835

Insured Information Rease complete all fields in this section.

Funeral HorneClaimFonn

Name of insured/deceased CJ F amily Coverage Riders Only

__ '__ '__ Date of death __ ,__ J__ Social Security nbr - - _

B_ Funeral Home Certificate of Death and Performance Please complete ell fields in this section.

The umJcni:ncli hc:n:b)' cct1i1ics thut the funeral home indiclitffi.1telow pe.rronncd the fllncrul services for the above named deceased.

~~~~~;~~:-~~~~:;~nefirr. section below must be completed for final c",!)e~ policies.) THX II) nbr -------Note: If above Tax ID number is registered with the IRS under a Parent/Holding company indicate name. _

Funeral home address. City State __ i'.i~1 _

Phone nhr'-~

CUU5e of death(check one): [J Natural 0 Accidental a Suicide/Homicide State ofresidenc~,l!~.~~'-·. _

Funds to be deposited through CJ iijQtiSi.ii'¢iiM or CI check to be mailed iQ.. f¥!leral hom~:.::!~i:.:·

Amount to he paid to funeral homo ~:~ =$:~::i!!~~m~#~;;'~~~Ol:~~dilferent]~:~~~h1g lunewlhomeI;.;;;;.,.;.U·.''".'Funeral Director's ticense nbr

C. fedel1ll Tax Wltilhoiding']nternal Revenue scrV¥8:~~W:~f.~.nsPlease check if you DO'NO'r"WifflU

s only.

taxable whhdrawals unless instructed otherwee.marked, taxes will be withheld I

o NO, I do not wish taxes withheld.

Complete for assiemnent after death.

______________ (pruned name), do hereby assign paymett in the amount of $ t;DGIbtAlnoulrlIl.tq.Jhd) Ito the funeral borne providing the services as noted above. I hereby certify that the indicated funeral home has fully and completelydelivered funeral aervicea andlor merchandise in the amount specified. ] agree that such payment of proceeds shall discharge, in full,all Iiability of the comp8l1Y under the poiicy(ies).Check one:

o ]am the beneficiary named in the policy. lfmultiple beneficiaries are named, all signatures art required.If any of the beneficlarres are deceased, theirdeath certocate is required. (Attach an additional document ifmore thantwo signatures are required}

If the beneficiary is the estate of the insured:

Cl ] am the Executor end/or Personal Representative of the estate.o There is no estate and 1 am the individual responsible for final arrangements for the Above named insured

Ma i1ing address City Stall: -- Zip IPhone nbr (~ Tax ID nbr (Beneficiary or Estate), _

Signature 0.1< __ '__ ' __

Wax·lli:o.a: Any person who knowingly, and with intent to injure, defraud 01 deceive any Insurer, makes any claim for the proceeds of aninsurance policy containing any false, incomplete OJ misleading Informancn is.guilty of a cnme.""TIlls formma.y be used for businessunzerwraten or administered by Un.ioo.Security Insurauce Compan.y or lAAmer:lcan.Ufe Insurance Compa.n.y.

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uired: Complete this section with deceased's information andICY numbers for claim.

ulred: Complete this section with performing Funeral Homeormation. The amount field must contain the dollar amount.

All Proceeds in the amount field is not acceptable.

plete this section for annuity products only.

plete for assignment after death. The dollar amount assignedmust be completed. All Proceeds in the amount field is notacceptable.

Note: When all proceeds are payable to the beneficiary completesections A, B, C and D and enter zero in the amount fields ofsections B and D. In addition, have the beneficiary sign in sectionD. Any existing assignment to the funeral home for the policieslisted will he considered released.

~.he following states have. additional requirements:~R: Seller's Affidavit of Contract Performance (FNL -Cl)p.Y, LA, NC & UT: Copy of Certified Death Certificate.'N: Copy of the statement of funeral merchandise and servicesigned by the Funeral Director and representative of the family.[X: Copy of Certified Death Certificate, copy of At-NeedI ontract and a certificate of performance

ASSURANT Solutions"Funeral Home

Claim Form2000 Wade Hampton Blvd.PO Box 19061Greenville, SC 29602-9061(800) 773-6333Please tax completed form to (888) 232-9835

A. Insured Information Please complete all fields in this section,

Policy nbr(s)

Name of insured/deceased _____. __._ _.__._.__.______ 0 Family Coverage Riders Only

Date of birth Date of death Social Security nbr . . _

B. Funeral Home Certificate of Death and Performance Please complete all fields in this section.

(must be pre-registered'>

Amount to be paid to funeral home $-=-=-=-_----:-:,------=-=_(Dollar Amount Required)

The undersigned hereby certifies that the funeral home indicated below performed the funeral services for the above named deceased.

Performing funeral home** --c~----,-,---..,--,-----,---..,.--:-_.____,,____,~---___.__c~~---Tax lD nbr 1(** The At-Need Assignment of Benefits section below must be completedfor final expense policies.)

Note: If above Tax ID number is registered with the IRS under a Parent/Holding company indicate name. ._.. _

Funeral home address City State Zip------------------------------------ --------- - ----Phone nbr( __ ) _

Cause of death (check one): 0 Natural

Funds to be deposited through 0

o Accidental D Suicide/Homicide State of residence at death

EjX.PRESS FUN DS or 0 check to be mailed to funeral home.

Name of funeral home if different from performing funeral home

Funeral Director's License nbr Signature of Funeral Director

C. Federal Tax Withholding Complete this section for annuity products only.

Intemal Revenue Service regulations require us to withhold 10% from taxable withdrawals unless instructed otherwise.Please check if you DO NOT wish taxes withheld. If not marked, taxes will be withheld.

D NO, I do not wish taxes withheld.

D. At-Need Assignment of Benefits Complete for assignment after death.

Signature

J . - .__._.__._.__._.... Tax ID nbr (Beneficiary OT Estate) . ._

Date

I, _. . . ._._. (printed name), do hereby assign payment in the amount of $ _(Dollar Amount RPJjuirOO)

to the funeral home providing the services as noted above. I hereby certify that the indicated funeral home has fully and completelydelivered funeral services and/or merchandise in the amount specified. r agree that such payment of proceeds shall discharge, in full,all liability of the company under the policy(ies).Check one:

o I am the beneficiary named in the policy. If multiple beneficiaries are named, all signatures are required.If any of the beneficiaries are deceased, their death certificate is required. (Attach an additional document if more thantwo signatures are required.)

If the beneficiary is the estate of the insured:

o I am the Executor and/or Personal Representative of the estate.Q There is no estate and I am the individual responsible for final arrangements for the above named insured.

Mailing address . . ..... ..__. ._. ._ City, .______________ ..._.. State . Zip .. ._

Phone nbr (

''\Iarning: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of aninsurance policy containing any false, incomplete or misleading information is guilty of a crime.

'"This form may be used for business underwritten or administered by Union Security Insurance Company or IAAmerican Life.Insurance Company.

©2010 Assurant Solutions, All Rights Reserved. • P,O. Box 19061 • Greenville, SC 29602-9061 • 1-800-773-6333CM-700 R0710 Page [of2