Symetra Life Insurance Company 777 108th Avenue NE, Suite 1200 Bellevue, WA 98004-5135 Mailing : Symetra Life Insurance Company PO Box 3882 Seattle, WA 98124-3882 Phone 1-800-796-3872 TTY/TDD 1-800-833-6388 CLAIMANT OPTION REQUEST Nonqualified Annuity Non-Spouse Beneficiary A. Decedent Information Name Annuity Number B. Claimant Information Name ( Please Print ) Mailing Date of Birth / / Telephone Number ( ) C. Death Benefit Election (Please select only one option) The value of the annuity contract you have inherited includes principal and interest. The interest is reportable as ordinary income and is taxable in the year(s) in which it is withdrawn. We encourage you to consult with a tax advisor prior to electing a payment option. Option 1 Begin distributions over my life expectancy within one year of the owner s death - Additional withdrawals may be taken at any time by notifying our office in writing. Payment Start Date / /. Frequency Monthly Quarterly Semi-annually Annually Mail checks to my address. Electronically credit (EFT) my Checking Savings account Must Attach a Voided Check Option 2 Distribute annuity within five years of the owner s death - Additional withdrawals may be taken at any time by notifying our office in writing. - It is your responsibility to deplete the annuity prior to the required date. Option 3 Receive a series of irrevocable payments (Annuitized payments) - Please contact our office for information on how to obtain a quote. - Payments must begin within one year of the owner s death and may not be stopped or altered. - Payments must be distributed over your lifetime or a number of years no greater than your life expectancy. Option 4 Receive entire amount in a lump sum distribution (Choose one option below): Secured Benefits Account If your approved benefit is $10,000 or more you may elect to have the proceeds paid through a free, interest bearing account opened in your name called a Secured Benefit Account (SBA). Here are some important facts about the Secured Benefit Account: - You will receive a personalized draft book so that you can access all or part of your money simply by writing a draft of $250 or more. - Your annuity benefits will begin earning interest as soon as your SBA account is opened and your funds will continue to earn interest while your account is active. Symetra and the Symetra Financial logo are registered service marks of Symetra Life Insurance Company. RIND-0080 12/10 Page 1 of 5
- Both your principal and any interest you earn are guaranteed by Symetra Life Insurance Company. The SBA is not insured by the Federal Deposit Insurance Corporation or any federal agency. - The establishment of a Secured Benefit Account satisfies our contractual obligation for the payment of annuity benefits. - If you would like more information about the Secured Benefit Account or one of the other payment options available, (does your contract offer other payment options?) please contact us toll free at 1-800-796-3872 ext. 23179. Mail a check to my address. D. New Beneficiary Information You may attach a separate sheet if needed. Primary Beneficiary 1. Name 2. Name Contingent Beneficiary 1. Name 2. Name E. Tax Withholding Election If a box is not selected, Symetra Life is required by IRS regulations to withhold 10% Federal Income Tax of the taxable portion of the distribution. We encourage you to consult your tax advisor. Federal Withholding: (IRS Form W-4P/OMB No. 1545-0074) Waive withholding of Federal Income Tax. I am liable for the payment of Federal Income Tax on the amount received. Withhold Federal Income Tax at a rate of % (not less than 10%) or $ (not less than $10) State Withholding: CA, DE, GA, IA, KS, MA, ME, NC, NE, OK, OR, VT, and VA residents only: State Income Tax must be withheld according to state requirements if Federal Income Tax is withheld. Waive withholding of State Income Tax. Withhold State Income Tax in the amount of $ or % of my Taxable or Federal Income Distribution Tax amount RIND-0080 12/10 Page 2 of 5
F. Claimant Signature Signature(s) must be notarized or Medallion Guaranteed I certify, under penalty of perjury, that the information above is true, correct, and complete to the best of my knowledge. I have read the fraud notices included with this statement. IRS Form W-9 / Part II (Certification): Under penalties of perjury, I certify that the number shown on this form is my correct taxpayer identification number, 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 a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and I am a U.S. citizen or other U.S. person. Claimant Name(s) (Please print) Claimant Signature Date Sign only when instructed to do so by the notary public or authorized officer Notary Form (To be completed by Notary Public) On this day personally appeared before me the person(s) who executed this instrument, and acknowledged that he/she signed the same as his/her free voluntary act and deed, for the uses and purposes therein mentioned. Given under my hand and official seal this on this day of, (month, year). State of Place seal or stamp here County of Signature of Notary Public My appointment expires Medallion Guarantee Must be completed by an authorized officer of an eligible guarantor institution, such as a bank that is a member of the Federal Deposit Insurance Corporation (FDIC), a trust company, or a member of a domestic stock exchange. Signature of Guarantor Place seal or stamp here Title / Name of Institution Date RIND-0080 12/10 Page 3 of 5
Claims Fraud Warning Any person who, with intent to defraud or knowing he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud. AK: AZ: AR, LA, RI, WV: CA: CO: DE: DC: FL: ID: IN: KY: 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. 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. 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. 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. 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. Any person who knowingly, and with intent to injure, defraud or deceive an insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. 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. 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. 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. Any person who knowingly and with intent to defraud or deceive an insurer files a statement of claim containing any false, incomplete or misleading information commits a felony. 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. RIND-0080 12/10 Page 4 of 5
ME: MD: MN: NH: NJ: NM: NY: OH: OK: PA: TN, VA, WA: TX: 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 denial of insurance benefits. Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who 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. A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. 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 N.H. Rev. Stat. Ann. 638:20. Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. 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. 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. 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. 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. 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. 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. 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. RIND-0080 12/10 Page 5 of 5