DEATH BENEFIT CLAIM PACKET

Athene Annuity & Life Assurance Company

Dear Customer :
These forms are to be used to file a death claim on a life insurance policy. We extend to you and the
family our sincere sympathy.
Please follow the instructions below and review the additional information on the back of this letter.
Step 1 The beneficiary should complete the Claimants Statement.
Step 2 Return completed Claimants statement and Certified Death Certificate to our service
center in the envelope provided.

Please see the back of this letter for additional instructions and information.
Thank you for allowing Athene Annuity to serve you during this difficult time. If we can help you further,
please contact us.
Sincerely,

Service Center

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Additional information for filing a death benefit claim

This packet should be used for death benefit claims for Athene Annuity & Life Assurance Company policies
and all company predecessors.
If there is more than one beneficiary, additional beneficiaries may use one Claimant Certificate or separate
certificates, if desired. If the beneficiary predeceased the insured, submit a copy of the beneficiarys death
certificate.
If the policy is payable to the Estate and probate proceedings are necessary, the Claimants Certificate
must be executed by the executor or administrator of the Insureds Estate. A certified copy of the court order
showing that the executor or administrator has qualified must also be submitted.
If the policy is payable to a minor or to a mentally incompetent person and a guardianship proceeding is
necessary, the Claimants Certificate should be executed by the guardian or conservator of the Estate of the
minor or incompetent person. A certified copy of letters of guardianship must also be submitted, even if the
guardian is the biological parent.
If the policy is payable as interest may appear, certified proof of this interest and the extent of it must be
furnished. If the policy has been assigned, or a power of attorney or other instrument affecting ownership to the
insurance has been executed, the original or a certified copy of such instrument must be enclosed. The
Company may require proof of any assignees interest.
Settlement Options Certain life policies may offer settlement options other than a lump sum benefit payment.
Please refer to your policy for any settlement options that may apply. If you have questions or need additional
settlement option information, please call the number listed on the bottom of Page 1.

Mailing Instructions:
If your policy number begins with MU mail to:
Athene Annuity & Life Assurance Service Center
PO Box 725449
Atlanta, GA 31139

For all other policy numbers mail to:

Athene Annuity & Life Assurance Service Center
PO Box 19038
Greenville, SC 29602

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Policy Number(s): ____________________________________________________________

Claimants Statement for Death Benefit
Name of Insured:
Address of Insured:
Social Security Number:

Date of Birth:

Date of Death

Cause of Death:
Did insured have multiple policies with our company or any of its predecessors?

Yes

No

Dont Know

AUTHORIZATION: I hereby authorize any insurance company, hospital, clinic, physician, surgeon, employer or practitioner to
furnish to any claims representative of Athene Annuity & Life Assurance Company, Greenville, South Carolina, or its
representative, any and all information concerning any illness or injury the insured may have suffered and copies of all
hospital or medical records, including all confidential HIV, communicable disease, alcohol or drug abuse, and mental health
information, so the same may be included as part of the Claim submitted to the Company. A reproduced copy of this
authorization shall be considered as effective and valid as the original.

BENEFICIARY INFORMATION: Complete for each beneficiary. Use back of this form if additional space is needed.
___________________________________________________________
Printed Name of Beneficiary

__________________________________
Social Security Number

X_________________________________________________________

___________________________________
Date

Signature

Address _____________________________________________________________________________________
Street
City
State
Zip
___________________________
Telephone Number

_______________________________
Date of Birth

______________________________________
Printed Name of Witness

_______________________________
Relationship to Deceased

X _____________________________________________
Signature of Witness

___________________________________________________________
Printed Name of Additional Beneficiary

__________________________________
Social Security Number

X_________________________________________________________

___________________________________
Date

Signature

Address _____________________________________________________________________________________
Street
City
State
Zip
___________________________
Telephone Number

_______________________________
Date of Birth

______________________________________
Printed Name of Witness

_______________________________
Relationship to Deceased

X _____________________________________________
Signature of Witness

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Certain Insurance Departments require that we advise you of the following statements:
For Alaska Residents: 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 Arizona Residents: 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.
For Alabama, Arkansas, Kentucky, Ohio, and West Virginia Residents: 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
maybe subject to fines and confinement in prison.
For California Residents: For your protection, California law requires the following to appear on this form: 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.
For Colorado Residents: 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 policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder 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.
For Delaware, Idaho and Indiana Residents: 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.
For District of Columbia Residents: 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.
For Florida Residents: 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.
For Louisiana, New Mexico and Rhode Island Residents: NOTICE: 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 Maine, Tennessee Virginia and Washington Residents: 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.
For Minnesota Residents: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a
crime.
For New Hampshire Residents: Any person who, with 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.
For New Jersey Residents: Any person who knowingly files a statement of claim containing any false or misleading information is
subject to criminal and civil penalties.
For Oklahoma Residents: 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.

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For Pennsylvania Residents: 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.
For Maryland Residents: 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.
LC3025

rev 7/18/12

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