Must be completed. If there are multiple Beneficiaries, please have each Beneficiary complete a separate claim form. Male

Transcription

1 Beneficiary Claim Form Mail to: Nationwide Life Insurance Company and Nationwide Life and Annuity Insurance Company Individual Annuities, P.O. Box , Columbus, Ohio, , , Fax to: Page 1 of 9 1. General Information Please print. 1a. Owner Information STOP For Estates or Trusts, please provide for each, Executor or Trustee information including Residential Address, Date of Birth, and Driver s License or Additional ID#. Please read these Options carefully. A copy of the Certified Death Certificate must accompany this form. If you have any questions regarding this form, please contact our Individual Annuity Service Center at Annuitant Name Existing Contract Number: (Required) Owner Name: Estate/Trust Name: Estate/Trust ITIN/EIN: Executor/Trustee Name: Same as Owner: 1b. Beneficiary Information An address MUST be provided for each Beneficiary. STOP Must be completed. If there are multiple Beneficiaries, please have each Beneficiary complete a separate claim form. Male Beneficiary Legal Name: Sex: Female Beneficiary SSN: Beneficiary (Required) Date of Birth: Residential Address: (No P.O. Box) City/State/ZIP: Mailing Address: (If different than residential) City/State/ZIP: Driver s License or Additional ID #: Phone Number: Address: Want a claim status? Provide an address and a status will be sent upon processing. 1c. Estate/Trust/Executor Information This Section is only required if the Estate/Trust is the Beneficiary. Executor/Trustee SSN: (Required) Residential Address: (No P.O. Box) City/State/ZIP: Mailing Address: (If different than residential) City/State/ZIP: Driver s License or Additional ID #: Phone Number: ( ) Address: ( ) Issue State: Executor/Trustee Date of Birth: Issue State: State ID Military ID Want a claim status? Provide an address and a status will be sent upon processing. Sex: State ID Military ID Male Female * A A F A O P 1 *

2 Beneficiary Claim Form Page 2 of 9 2. Claim Options Select only one Option (Option 1 - Option 6), as applicable. A spouse may elect any claim option, but a non-spouse, including those partners in civil unions may only select from Options 3, 4, 5 or 6. No Current Distribution Requested (If you do not want to receive income now and pay taxes in the current tax year now, please choose Options 1, 2 or 3.) Option 1 Available to surviving spouses This option is only available to the Contract Owner, Annuitant or Co-Annuitant s surviving spouse. This option allows a surviving spouse to remain the current owner of the contract or to become the new contract owner. The Annuity Commencement Date* will automatically be updated to the new annuitant s 95th birthday, unless another future date is indicated below: Annuity Commencement Date: / / (Optional) MM DD YYYY *Annuity Commencement Date (ACD) is the date on which annuity payments are scheduled to begin. If you have not elected to annuitize by the date listed above, we ll send you annual notices. Option 2 Option 3 Spouse chooses to be retitled as a Beneficial Owner (Qualified annuity contracts only) Under this option the surviving spouse may delay taking distributions until the deceased spouse would have turned 70 1/2. If you need to take withdrawals in the future, they are not subject to 10% additional tax for premature distributions. You will also need to complete the New Beneficiaries Section of this form. Delay income for up to five years Available for all Non Qualified contracts and if eligible Qualified Contracts (all IRAs, as well as 401, 403(b) and Governmental 457 (b) plans). This option allows the Beneficiary to delay taking income for up to five years after the date of death (see pages 7 through 9 for eligibility and election information, as well as time limitations). You will also need to complete the New Beneficiaries Section of this form. Option 4 Option 5 Distribution Requested (If you want income now, please select an option from Options 4, 5 or 6.) Annuitization This option allows you to annuitize the contract, which means you can convert the contract value into a guaranteed income stream where you elect how long you will receive these payments. You can have a lifetime payout or a guaranteed number of years (e.g. 10 year guaranteed payout). In order to provide this option, a Deferred Annuitization Election Form will need completed. Please call if you have any questions. Life Expectancy Scheduled Withdrawals (You must complete Sections 5a and 5b.) This option allows you to schedule withdrawals based on the original Beneficiary s life expectancy. See page 8 for election details as well as the time limitations for making this election. You must also complete the New Beneficiaries Section of this form. Complete Sections 5a and 5b on the following page. Claim Options continued on Page 3. * A A F A O P 2 *

3 Beneficiary Claim Form Page 3 of 9 2. Claim Options Continued. If this Section is blank, we will default to current day. 5a. Program Information Withdrawal Frequency (Please select one option.) Annually Semi-Annually Quarterly Monthly* *You can receive withdrawals by direct deposit for any frequency, but you must choose direct deposit for monthly payment options. Start date / / MM DD YYYY 5b. Method of Payment (Only for Life Expectancy Scheduled Withdrawals (Option 5) Direct Deposit Open a Nationwide Bank Secure Money Market account (See benefits on page 9.) OR Another financial institution (You must complete the information below and provide a voided check or letter from your bank. This option is only available for Life Expectancy Scheduled Withdrawals.) Financial institution Name: Financial institution Phone Number: ( ) You must attach a voided check if depositing to your checking account. If depositing to your savings account, a letter from your financial institution will be required. The deposit to your checking or savings account will normally occur two (2) business days after the date of the scheduled withdrawal from your annuity contract. If you change your bank/financial institution, please notify Nationwide immediately. Deposit slips, starter checks, and bank drafts are not acceptable. Note: If no voided check (or letter from your bank/financial institution) is included, a check will automatically be mailed to the Beneficiary s address in Section 1b unless an alternate address is provided below. Alternate address: Option 6 If this Section is blank, we will default to sending a check to the Beneficiary. Lump Sum Payment Option - Direct Deposit or Single Check Directly to Beneficiary This option allows the Beneficiary to receive full payment made by direct deposit to either a newly opened Nationwide Bank Secure Money Market Account, a financial institution of their choosing, or by receipt of a check made payable to the Beneficiary. Select only one method of payment from Section 6a or 6b. 6a. Direct Deposit Open a Nationwide Bank Secure Money Market account An attractive variable tiered rate of interest A safe account to hold funds separate from your everyday funds FDIC insurance coverage, up to $250,000 per depositor Dedicated Customer Care Specialists ready to help you when you call them at Ability to consolidate funds from other sources OR Another financial institution (You must complete the information below and provide a voided check or letter from your bank.) For a transfer or 1035 exchange, a signed letter of acceptance must be included. Deposit slips, starter checks, and bank drafts are not acceptable. Financial institution Name: Financial institution Phone Number: ( ) You must attach a voided check if depositing to your checking account. If depositing to your savings account, a letter from your financial institution will be required. Note: If no voided check (or letter from your bank/ financial institution) is included, a check will automatically be mailed to the Beneficiary s address in Section 1b. OR 6b. Check (A check will be mailed to you, using the address provided on page 1, Section 1b or 1c.) * A A F A O P 3 *

4 Beneficiary Claim Form Page 4 of 9 3. New Beneficiaries Section If more than two beneficiaries, use the Additional Beneficiaries Form. Allocation to all Primary Beneficiaries must equal 100% Contingent Beneficiaries must also equal 100% You must complete this Section if choosing Claim Option 1, 2, 3 or 5 If the Beneficiary is a trust, include trust paperwork 3a. Primary Beneficiaries Pay all Primary Beneficiaries equally Legal First Name: MI: Last Name: Relationship to Annuitant: Allocation (whole % only): % SSN #: Sex: M F Date of Birth: Address: Same address as owner Street: City: State: ZIP: Address: Daytime Phone Number: ( ) Legal First Name: MI: Last Name: Relationship to Annuitant: Allocation (whole % only): % SSN #: Sex: M F Date of Birth: Address: Same address as owner Street: City: State: ZIP: Address: Daytime Phone Number: ( ) Legal First Name: MI: Last Name: Relationship to Annuitant: Allocation (whole % only): % SSN #: Sex: M F Date of Birth: Address: Same address as owner Street: City: State: ZIP: Address: Daytime Phone Number: ( ) 3b. Contingent Beneficiary Legal First Name: MI: Last Name: Relationship to Annuitant: Allocation (whole % only): % SSN #: Sex: M F Date of Birth: Address: Same address as owner Street: City: State: ZIP: Address: Daytime Phone Number: ( ) You must complete all fields. * A A F A O P 4 *

5 Beneficiary Claim Form Page 5 of 9 4. State Fraud Disclosure Alabama: Any person who submits an application or a claim containing a false or deceptive statement, and does so with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, is guilty of insurance fraud and may be subject to fines and/or confinement in prison. Alaska, Connecticut, Georgia, Hawaii, Illinois, Iowa, Massachusetts, Michigan, Minnesota, Mississippi, Montana, Nebraska, New Hampshire, Ohio, South Carolina, South Dakota, Utah, Vermont, Wisconsin and Wyoming: Any person who submits an application or a claim containing a false or deceptive statement, and does so with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, may be guilty of insurance fraud. Arkansas, Rhode Island, Texas and 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 and confinement in prison. 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. California: For your protection California law requires the following to appear on this form. Any person who knowingly presents 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. Colorado: Important Notice: 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 or regulatory agencies. Delaware, Idaho, Indiana and Oklahoma: 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. District of Columbia 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. Kansas, Nevada, North Carolina and North Dakota: Any person who submits an application or a claim containing a false or deceptive statement, and does so with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, may be guilty of insurance fraud. Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a 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. Louisiana: Any person who knowingly presents 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 and confinement in prison. Maine, Tennessee, Virginia and 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. Maryland: Applicable to all claim forms signed on or before December 31, 2012: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Applicable to all claim forms signed on or after January 1, 2013: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or 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. Missouri Caution: If your answers on this application are incorrect or untrue, Nationwide has the right to deny benefits or rescind your policy. Fraud Statement: Any person who submits an application or a claim containing a false or deceptive statement, and does so with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, may be guilty of insurance fraud. 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. * A A F A O P 5 *

6 Beneficiary Claim Form Page 6 of 9 4. State Fraud Disclosure (Continued) New York: 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. Oregon: 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 fraudulent information, materially false information, or conceal for the purpose of misleading information concerning any fact material thereto, upon which the insurance company or other person relies may be guilty of insurance fraud and subject to prosecution. 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 with the penalty of a fine of not less then five thousand (5,000) dollars and not more than ten thousand (10,000) dollars, 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. 5. Tax Withholding Elections For state withholding, please list your state of residence: Certification - I certify under penalties of perjury that: 1) The number shown on this form is my correct taxpayer identification number, and If this Section is blank, 10% federal tax and any required state tax will be withheld. Do not withhold taxes If you wish to have taxes withheld, complete below. Federal Withholding % State Withholding % 2) I am not subject to backup withholding because (a) I have not been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (b) the Internal Revenue Service has notified me that I am no longer subject to backup withholding, or that I am exempt from backup withholding, and 3) I am a U.S. person (including a U.S. resident alien). You must cross out item (2) if you have been notified by the IRS that you are currently subject to backup withholding because of failure to report interest or dividends on your tax return. The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. 6. Disclosures and Signature(s) THE GUARANTEED DEATH BENEFIT AMOUNT IS DETERMINED UPON RECEIPT OF THE FIRST VALID BENEFICIARY CLAIM FORM. IF THERE IS MORE THAN ONE BENEFICIARY AND THE PROCEEDS ARE INVESTED IN VARIABLE FUNDS THE BALANCE OF THE CONTRACT VALUE WILL BE EXCHANGED INTO THE MONEY MARKET SUB-ACCOUNT, IF THE CONTRACT QUALIFIES FOR THIS TYPE OF EXCHANGE. OTHER- WISE, THE BALANCE WILL REMAIN IN THE CURRENT UNDERLYING SUB ACCOUNTS AND WILL FLUCTUATE DUE TO MARKET ACTIVITY AND MAY BE SUBJECT TO LOSS OF VALUE. Please consult your annuity prospectus and contract for specific payout information. You may want to consult with your Investment Professional for assistance in determining the claim option that is best suited for your financial situation. You may want to consult an attorney or tax advisor for answers to tax questions. If I select the Nationwide Bank Secure Money Market account, I authorize Nationwide Life Insurance Company to share only the personal information required to open an account for me with the Nationwide Bank, a Nationwide affiliate. I represent that the information provided herein is true and accurate. Beneficiary s/executor s/trustee s Signature: X Date: Custodian s/co-executor s/co-trustee s Signature: X Date: * A A F A O P 6 *

7 Beneficiary Claim Form Page 7 of 9 Additional Details for Each Claim Option PLEASE RETAIN FOR YOUR RECORDS. DO NOT RETURN WITH COMPLETED BENEFICIARY CLAIM FORM. Option 1 Available to surviving spouses option available to the surviving spouse only. Pursuant to Section 3 of the Federal Defense of Marriage Act ( DOMA ), same sex marriages currently are not recognized for purposes of federal law. Therefore, the favorable income-deferral options afforded by federal tax law to an opposite sex spouse under Internal Revenue Code Sections 72(s) and 401(a)(9) are currently NOT available to a same sex spouse. Same sex spouses who own or are considering the purchase of annuity products that provide benefits based upon status as a spouse should consult a tax advisor. To the extent that an annuity contract or certificate accords to spouses other rights or benefits that are not affected by DOMA, same sex spouses remain entitled to such rights or benefits to the same extent as any annuity holder s spouse No distributions are required Allows the spouse to continue the annuity contract as owner and annuitant. If spouse is younger than 59 1/2 he/she may be subject to 10% additional tax for premature distributions New Beneficiaries can be named. Please make sure allocations equal 100% for all Primary Beneficiaries and 100% for Contingent Beneficiaries The Annuity Commencement Date (ACD) will automatically be updated based upon the new annuitant s information and the terms of the contract unless otherwise stated Contract continues same as before the death occurred but will be tax reported to a surviving spouse upon distribution of the funds Exchanges are permitted between the underlying funds available with the contract If there is only one Beneficiary, the contract will remain invested in the same manner as that of the decedent until the Beneficiary provides new fund allocation instructions Option 2 Spouse chooses to be retitled as a Beneficial Owner option available to the surviving spouse only. Pursuant to Section 3 of the Federal Defense of Marriage Act ( DOMA ), same sex marriages currently are not recognized for purposes of federal law. Therefore, the favorable income-deferral options afforded by federal tax law to an opposite sex spouse under Internal Revenue Code Sections 72(s) and 401(a)(9) are currently NOT available to a same sex spouse. Same sex spouses who own or are considering the purchase of annuity products that provide benefits based upon status as a spouse should consult a tax advisor. To the extent that an annuity contract or certificate accords to spouses other rights or benefits that are not affected by DOMA, same sex spouses remain entitled to such rights or benefits to the same extent as any annuity holder s spouse Under this option the surviving spouse is electing to be treated as a Beneficiary The contract must be an IRA of any type, 401, 403(b) Tax Sheltered Annuity (TSA), or Governmental 457 plan to elect this option Spouses from Non-qualified contacts must chose Option 1 (Available to Surviving Spouses) or Option 3 (Delay income for up to five years), if they wish to delay distributions Distributions are not required until the later of the year the deceased spouse would have reached age 70 1/2 or by December 31st of the year after the year of death This option will automatically default to Option 1, Available to Surviving Spouses, if additional contributions are made in the contract by the spouse OR if required distributions are not made when required, as described in the previous bullet If the surviving spouse dies before they are required to begin receiving distributions, he or she will be treated as the owner of the IRA If the surviving spouse remarries, their new spouse can not continue beneficial treatment upon their death Withdrawals can be requested at any time in writing and are not subject to the 10% additional tax for premature distributions Exchanges are permitted between the underlying funds available with the contract If there is only one Beneficiary, the contract will remain invested in the same manner as that of the decedent until the Beneficiary provides new fund allocation instructions Option 3 Delay income for up to five years the entire proceeds have to be liquidated by December 31st of the fifth year of the decedent s (the person who passed away) date of death. For Qualified Money contracts (401, 403(b), Governmental 457(b), and all IRA types), this option is not available if the required beginning date for Required Minimum Distributions (RMD) has already occurred. Normally the required beginning date is April 1 of the year following the year the decedent would have turned 70 1/2. For 401, 403(b), and 457(b) plans, this would be the date of retirement, if that date occurs after April 1 of the year after the decedent would have turned 70 1/2 For Non Qualified contracts, if no other election is made within one year from the decedent s date of death, we will default to this option and total distribution must occur by the end of the fifth year from the year of the decedent s death For example, if the death occurred on 6/01/2001, election must be made by 5/31/2002 For all IRA as well as, 401, 403(b) and Governmental 457(b) plans, this option must be made by December 31st of the year after the decedent s death The entire contract value must be distributed by December 31st of the fifth year after the decedent s date of death for IRAs, 401, 403(b), and 457(b) governmental plan types. For non-qualified annuity contracts, the entire contract value must be distributed by the 5th year anniversary of the decedent s date of death Option 3 detail continues on page 8. * A A F A O P 7 *

8 Beneficiary Claim Form Page 8 of 9 Option 3 Delay income for up to five years the entire proceeds have to be liquidated by December 31st of the fifth year of the decedent s (the person who passed away) date of death. (Continued) The distribution amount from the annuity, if taxable, will be reported to the IRS and you by Nationwide Life Insurance Company for the calendar year the money is distributed No new deposits are permitted New successor Beneficiaries can be named. Please complete the New Beneficiaries Section of this form and make sure the allocations equal 100% for all Primary Beneficiaries and 100% for Contingent Beneficiaries Exchanges are permitted between the underlying funds available with the contract Your funds are available for withdrawal at any time. Distributions/withdrawals will occur only upon written instruction from you The amount you request will be mailed directly to the address you give us under the Beneficiary information Section, unless you fill out an alternate address Any tax withholding instructions should be indicated in the Tax Withholding Election Section of this form. If no tax withholding instructions are provided, we will automatically withhold 10% federal income taxes as well as any applicable mandatory state taxes If there is only one Beneficiary, the contract will remain invested in the same manner as that of the decedent until the Beneficiary provides new fund allocation instructions ***All non-spousal Beneficiaries will receive a new, separate, Beneficial Owner contract with a new contract number. If there are multiple Beneficiaries, the portion each Beneficiary claims will be retitled to his/her own contract with a new contract number, as a Beneficial Owner. The new contract will be allocated to the available money market sub-account until new instructions are received by the new Beneficial Owner. Option 4 Annuitization This option allows for the proceeds to be distributed in the form of guaranteed payments Several options are available. If elected, our Income Products Service Center will provide you with further information and quotes This option must be elected within 60 days after all good order requirements have been received and Nationwide is obligated to release the funds to the Beneficiary Option 5 Life Expectancy Scheduled Withdrawals Nationwide will establish distributions payable to the beneficial owner based on the life expectancy of the original Beneficiary The distributions are based upon the original Beneficiary s life expectancy, using a life expectancy table. The amount is calculated each year and you must take withdrawals at least annually For Qualified contracts (all IRA s as well as 401, 403(b) and Governmental 457(b) plans) the election of this option must be made and distributions must begin by December 31st of the year after the decedent s death For Non Qualified contracts the election of this option must be made and distributions must begin within one year following the year of the decedent s death. For example, if the death occurred on June 1, 2001, distributions must begin by May 31, 2002 For Death Benefit proceeds from a Qualified Plan, such as a 401, 403(b) or Governmental 457(b) plan, these may be rolled over to a Beneficial Owned IRA contract New Beneficiaries can be named. Please make sure Beneficiary allocations equal 100% for all Primary Beneficiaries and 100% for Contingent Beneficiaries As long as the decedent is the same, you may combine these funds with another Beneficially Owned IRA (i.e., Inherited IRA) at Nationwide as a direct rollover The frequency and start date for these withdrawals must be provided by you by completing the Program Information The amount will be mailed directly to the address you give us under the Beneficiary information Section, unless you fill out an alternate address Your funds are available for withdrawal at any time. Distributions/withdrawals in addition to the scheduled withdrawals will occur only upon written instruction from you The distribution amount from the annuity, if taxable, will be reported to the IRS and you by Nationwide Life Insurance Company for the calendar year the money is distributed Any tax withholding instructions should be indicated in the Tax Withholding Election Section of this form. If no tax withholding instructions are provided, we will automatically withhold 10% federal income taxes as well as any applicable mandatory state taxes. No new deposits are permitted Exchanges are permitted between the underlying funds If there is only one Beneficiary, the contract will remain invested in the same manner as that of the decedent until the Beneficiary provides new fund allocation instructions ***All non-spousal Beneficiaries will receive a new, separate, Beneficial Owner contract with a new contract number. If there are multiple Beneficiaries, the portion each Beneficiary claims will be retitled to his/her own contract with a new contract number, as a Beneficial Owner. The new contract will be allocated to the available money market sub-account until new instructions are received by the new Beneficial Owner. * A A F A O P 8 *

9 Beneficiary Claim Form Page 9 of 9 Option 6 Lump sum payment option - direct deposit or single check directly to Beneficiary The amount may be directly deposited into a Nationwide Bank Secure Money Market account or the Beneficiary s own bank account. You must complete the Direct Deposit option in the Method of Payment Section. If you want the amount deposited into the Beneficiary s own bank account, you must also provide a voided check or a letter from your financial institution The amount you request will be mailed directly to the address you indicate under the Beneficiary information in Section 1b, unless you have chosen direct deposit or complete the Alternate Address information in the Method of Payment Section The distribution amount from the annuity, if taxable, will be tax reported to the Beneficiary by Nationwide Life Insurance Company for the calendar year that the money is distributed on form 1099R Any tax withholding instructions should be indicated in the Tax Withholding Election Section 5 of this form. If no tax withholding instructions are provided, we will automatically withhold 10% Federal Income Taxes as well as any applicable mandatory State Taxes Important Information about the Nationwide Bank Secure Money Market Account Nationwide Bank is an affiliate of Nationwide Life Insurance Company and Nationwide Life and Annuity Insurance Company ( the Life Companies ). You may send correspondence to Nationwide Bank at P.O. Box , Columbus, OH The Nationwide Bank Secure Money Market Account is not a Retained Asset Account (i.e. is not held, administered, or controlled by the Life Companies). If elected, your funds will be transferred to your own money market account established with Nationwide Bank. Interest rates are set by Nationwide Bank and are available at or by calling I-BANK-NW ( ). You should check current rates, fees, and services, compare with other available options, and consult with your financial and/or tax advisor before choosing the Nationwide Bank Secure Money Market Account for your settlement option. Once your Nationwide Bank Secure Money Market Account is established and your funds transmitted to your bank account, the Life Companies will no longer have any access to your funds or account information The Nationwide Bank Secure Money Market Account has a minimum balance requirement of $250. If the balance falls below the minimum, your account will be closed and a check for the remaining balance will be issued to you The distribution amount from the life insurance policy or annuity contract, if taxable, will be reported to the IRS and you by the Life Companies for the calendar year the money is deposited into the Nationwide Bank Secure Money Market Account. Any interest earned from the Nationwide Bank Secure Money Market Account after deposit will be taxable in the year it is credited to your account and will be reported to the IRS by Nationwide Bank Fees: Official Checks: $8.00 Stop payments on checks or ACH transactions: $20.00 Paper copies of canceled checks: $5.00 Non-Nationwide Bank ATM use: $1.50 per transaction, after the first two per statement cycle. Surcharges from the ATM owner may apply No monthly service fees, free electronic transfers to outside bank accounts, free personalized checks, and ATM card provided at your request Other Banking information: FDIC insurance coverage of at least $250,000 per depositor Ability to consolidate funds from other sources Interest rates may vary based on account balances The entire account balance can be accessed with a single check Paper or electronic monthly statements summarizing all activity and transaction details Dedicated support from Customer Care Specialists ready to help you when you call them at I-BANK-NW ( ) To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: when you open an account with Nationwide Bank, we ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver s license or other identifying documents * A A F A O P 9 *