Federal housing law
1224 Form 712 (PDF)
Federal housing law as enacted — verbatim and citable.
- Edition
- 2026-10-03
- Last updated
- 2026-10-04
- Jurisdiction
- United States
Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f712.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).
Form
712¶
Life Insurance Statement¶
OMB No. 1545-0022
Department of the Treasury Go to www.irs.gov/Form712 for the latest information. Internal Revenue Service
Part I Decedent—Insured (To be filed by the executor with Form 706, United States Estate (and Generation-Skipping Transfer) Tax Return, or Form 706-NA, United States Estate (and Generation-Skipping Transfer) Tax Return, Estate of nonresident not a citizen of the United States.)
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 5a Name of insurance company |
5a Name of insurance company |
5a Name of insurance company |
5b Address (number and street) of insurance company |
5b Address (number and street) of insurance company |
5b Address (number and street) of insurance company |
5b Address (number and street) of insurance company |
5c City |
5c City |
5d State | 5d State | 5e ZIP code |
| 6 Type of policy |
6 Type of policy |
6 Type of policy |
6 Type of policy |
6 Type of policy |
6 Type of policy |
6 Type of policy |
7Policy number |
7Policy number |
7Policy number |
7Policy number |
7Policy number |
| 8Owner’s name. If decedent is not owner, attach copy of application. |
8Owner’s name. If decedent is not owner, attach copy of application. |
8Owner’s name. If decedent is not owner, attach copy of application. |
9Date issued |
9Date issued |
10 Assignor’s name. Attach copy of assignment. |
10 Assignor’s name. Attach copy of assignment. |
10 Assignor’s name. Attach copy of assignment. |
10 Assignor’s name. Attach copy of assignment. |
11 Date assigned | 11 Date assigned | 11 Date assigned |
| 12Value of the policy at the time of assignment |
13 Amount of premium (see instructions) |
13 Amount of premium (see instructions) |
13 Amount of premium (see instructions) |
14Name of beneficiaries | 14Name of beneficiaries | 14Name of beneficiaries | 14Name of beneficiaries | 14Name of beneficiaries | 14Name of beneficiaries | 14Name of beneficiaries | 14Name of beneficiaries |
| 15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 |
|||||||||
| Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 | 15 |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 |
|||||||||
| Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
16 | 16 |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 |
|||||||||
| Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
17 | 17 |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 |
|||||||||
| Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
18 | 18 |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 |
|||||||||
| Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
19 | 19 |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 |
|||||||||
| Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
20 | 20 |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 |
|||||||||
| Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
21 | 21 |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 |
|||||||||
| Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
22 | 22 |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 |
|||||||||
| Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
23 | 23 |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 |
|||||||||
| Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
24 | 24 |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 |
|||||||||
| Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
25 | 25 |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 |
|||||||||
| Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
27 | 27 |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 |
|||||||||
| Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 |
| 1 Decedent’s first name and middle initial |
2 Decedent’s last name | 3 Decedent’s social security number (if known) |
4 Date of death | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . . 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. (i) Name of person the duration of whose life may measure beyond the number of payments (ii) Date of birth (iii) Sex 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . |
29 | 29 |
30 Basis (mortality table and rate of interest) used by insurer in valuing installment benefits.
31 Were there any transfers of the policy within the 3 years prior to the death of the decedent? . . . . . Yes No 32 If you checked “Yes” on line 31, enter date of assignment or transfer: / / Month Day Year
33 Was the insured the annuitant or beneficiary of any annuity contract issued by the company? . . . . . Yes No 34 Did the decedent have any incidents of ownership on any policies on the decedent’s life, but not owned by the decedent at the date of death? . . . . . . . . . . . . . . . . . . . . . . . . Yes No 35 Names of companies with which decedent carried other policies and amount of such policies if this information is disclosed by your records.
The undersigned officer of the above-named insurance company (or appropriate federal agency or retirement system official) hereby certifies that this statement sets forth true and correct information.
Signature Title
Date of Certification
For Privacy Act and Paperwork Reduction Act Notice, see instructions. Cat. No. 10170V Form 712 (Rev. 12-2024)
Form 712 (Rev. 12-2024) Page 2 Part II Living Insured (File with Form 709, United States Gift (and Generation-Skipping Transfer) Tax Return, and Form 709-NA, United States Gift (and Generation-Skipping Transfer) Tax Return on Nonresident Not a Citizen of the United States. May also be filed with Form 706, United States Estate (and Generation-Skipping Transfer) Tax Return, or Form 706-NA, United States Estate (and Generation-Skipping Transfer) Tax Return, Estate of nonresident not a citizen of the United States, where decedent owned insurance on life of another.)
SECTION A—General Information
36 First name and middle initial of donor (or decedent) 37 Last name 38 Social security number
39 Date of gift for which valuation data submitted . . . . . . . . . . . . . . . 39 40 Date of decedent’s death for which valuation data submitted . . . . . . . . . . . 40
| SECTION B—Policy Information 41 Name of insured | 42 Sex | 43 Date of birth | |||||
|---|---|---|---|---|---|---|---|
| 41Name of insured |
41Name of insured |
41Name of insured |
41Name of insured |
41Name of insured |
42Sex |
43Date of birth |
43Date of birth |
| 44a Name of insurance company |
44b Address (number and street) of insurance company |
44b Address (number and street) of insurance company |
44c City |
44c City |
44c City |
44d State |
44e ZIP code |
| 45Type of policy |
46Policy number | 46Policy number | 47Face amount |
47Face amount |
47Face amount |
48Issue date |
48Issue date |
| 49Gross premium |
49Gross premium |
49Gross premium |
50Frequency of payment |
50Frequency of payment |
50Frequency of payment |
50Frequency of payment |
50Frequency of payment |
| 51Assignee’s name |
51Assignee’s name |
51Assignee’s name |
51Assignee’s name |
51Assignee’s name |
51Assignee’s name |
52Date assigned |
52Date assigned |
| 53If irrevocable designation of beneficiary made, name of beneficiary |
53If irrevocable designation of beneficiary made, name of beneficiary |
54Sex |
54Sex |
55 Date of birth, if known |
55 Date of birth, if known |
56Date designated | 56Date designated |
| 58 If policy is not paid up: a Interpolated terminal reserve on date of death, assignment, or irrevocable designation of beneficiary . . . . . . . . . . . 58a b Add proportion of gross premium paid beyond date of death, assignment, or irrevocable designation of beneficiary . . . . . . . . . . . 58b c Add adjustment on account of dividends to credit of policy . . . . 58c d Total. Add lines 58a, b, and c . . . . . . . . . . . . . . . . . . . . . . . e Outstanding indebtedness against policy . . . . . . . . . . . . . . . . . . . f Net total value of the policy (for gift or estate tax purposes). Subtract line 58e from line 58d . . . 59 If policy is either paid up or a single premium: a Total cost, on date of death, assignment, or irrevocable designation of beneficiary, of a single-premium policy on life of insured at attained age, for original face amount plus any additional paid-up insurance (additional face amount ) . . . . . . . . 59a (If a single-premium policy for the total face amount would not have been issued on the life of the insured as of the date specified, nevertheless, assume that such a policy could then have been purchased by the insured and state the cost thereof, using for such purpose the same formula and basis employed, on the date specified, by the company in calculating single premiums.) b Adjustment on account of dividends to credit of policy . . . . . . 59b c Total. Add lines 59a and 59b . . . . . . . . . . . . . . . . . . . . . . . d Outstanding indebtedness against policy . . . . . . . . . . . . . . . . . . . e Net total value of policy (for gift or estate tax purposes). Subtract line 59d from line 59c . . . . |
58a | 58d | ||
|---|---|---|---|---|
| 58 If policy is not paid up: **a **Interpolated terminal reserve on date of death, assignment, or irrevocable designation of beneficiary . . . . . . . . . . . 58a **b **Add proportion of gross premium paid beyond date of death, assignment, or irrevocable designation of beneficiary . . . . . . . . . . . 58b **c **Add adjustment on account of dividends to credit of policy . . . . 58c **d Total.**Add lines 58a, b, and c . . . . . . . . . . . . . . . . . . . . . . . **e **Outstanding indebtedness against policy . . . . . . . . . . . . . . . . . . . **f ** Net total value of the policy (for gift or estate tax purposes). Subtract line 58e from line 58d . . . 59 If policy is either paid up or a single premium: **a ** Total cost, on date of death, assignment, or irrevocable designation of beneficiary, of a single-premium policy on life of insured at attained age, for original face amount plus any additional paid-up insurance (additional face amount ) . . . . . . . . 59a (If a single-premium policy for the total face amount would not have been issued on the life of the insured as of the date specified, nevertheless, assume that such a policy could then have been purchased by the insured and state the cost thereof, using for such purpose the same formula and basis employed, on the date specified, by the company in calculating single premiums.) **b **Adjustment on account of dividends to credit of policy . . . . . . 59b **c Total.**Add lines 59a and 59b . . . . . . . . . . . . . . . . . . . . . . . **d **Outstanding indebtedness against policy . . . . . . . . . . . . . . . . . . . **e **Net total value of policy (for gift or estate tax purposes). Subtract line 59d from line 59c . . . . |
58b | |||
| 58 If policy is not paid up: **a **Interpolated terminal reserve on date of death, assignment, or irrevocable designation of beneficiary . . . . . . . . . . . 58a **b **Add proportion of gross premium paid beyond date of death, assignment, or irrevocable designation of beneficiary . . . . . . . . . . . 58b **c **Add adjustment on account of dividends to credit of policy . . . . 58c **d Total.**Add lines 58a, b, and c . . . . . . . . . . . . . . . . . . . . . . . **e **Outstanding indebtedness against policy . . . . . . . . . . . . . . . . . . . **f ** Net total value of the policy (for gift or estate tax purposes). Subtract line 58e from line 58d . . . 59 If policy is either paid up or a single premium: **a ** Total cost, on date of death, assignment, or irrevocable designation of beneficiary, of a single-premium policy on life of insured at attained age, for original face amount plus any additional paid-up insurance (additional face amount ) . . . . . . . . 59a (If a single-premium policy for the total face amount would not have been issued on the life of the insured as of the date specified, nevertheless, assume that such a policy could then have been purchased by the insured and state the cost thereof, using for such purpose the same formula and basis employed, on the date specified, by the company in calculating single premiums.) **b **Adjustment on account of dividends to credit of policy . . . . . . 59b **c Total.**Add lines 59a and 59b . . . . . . . . . . . . . . . . . . . . . . . **d **Outstanding indebtedness against policy . . . . . . . . . . . . . . . . . . . **e **Net total value of policy (for gift or estate tax purposes). Subtract line 59d from line 59c . . . . |
58c | |||
| 58 If policy is not paid up: **a **Interpolated terminal reserve on date of death, assignment, or irrevocable designation of beneficiary . . . . . . . . . . . 58a **b **Add proportion of gross premium paid beyond date of death, assignment, or irrevocable designation of beneficiary . . . . . . . . . . . 58b **c **Add adjustment on account of dividends to credit of policy . . . . 58c **d Total.**Add lines 58a, b, and c . . . . . . . . . . . . . . . . . . . . . . . **e **Outstanding indebtedness against policy . . . . . . . . . . . . . . . . . . . **f ** Net total value of the policy (for gift or estate tax purposes). Subtract line 58e from line 58d . . . 59 If policy is either paid up or a single premium: **a ** Total cost, on date of death, assignment, or irrevocable designation of beneficiary, of a single-premium policy on life of insured at attained age, for original face amount plus any additional paid-up insurance (additional face amount ) . . . . . . . . 59a (If a single-premium policy for the total face amount would not have been issued on the life of the insured as of the date specified, nevertheless, assume that such a policy could then have been purchased by the insured and state the cost thereof, using for such purpose the same formula and basis employed, on the date specified, by the company in calculating single premiums.) **b **Adjustment on account of dividends to credit of policy . . . . . . 59b **c Total.**Add lines 59a and 59b . . . . . . . . . . . . . . . . . . . . . . . **d **Outstanding indebtedness against policy . . . . . . . . . . . . . . . . . . . **e **Net total value of policy (for gift or estate tax purposes). Subtract line 59d from line 59c . . . . |
58c | 58e | ||
| 58 If policy is not paid up: **a **Interpolated terminal reserve on date of death, assignment, or irrevocable designation of beneficiary . . . . . . . . . . . 58a **b **Add proportion of gross premium paid beyond date of death, assignment, or irrevocable designation of beneficiary . . . . . . . . . . . 58b **c **Add adjustment on account of dividends to credit of policy . . . . 58c **d Total.**Add lines 58a, b, and c . . . . . . . . . . . . . . . . . . . . . . . **e **Outstanding indebtedness against policy . . . . . . . . . . . . . . . . . . . **f ** Net total value of the policy (for gift or estate tax purposes). Subtract line 58e from line 58d . . . 59 If policy is either paid up or a single premium: **a ** Total cost, on date of death, assignment, or irrevocable designation of beneficiary, of a single-premium policy on life of insured at attained age, for original face amount plus any additional paid-up insurance (additional face amount ) . . . . . . . . 59a (If a single-premium policy for the total face amount would not have been issued on the life of the insured as of the date specified, nevertheless, assume that such a policy could then have been purchased by the insured and state the cost thereof, using for such purpose the same formula and basis employed, on the date specified, by the company in calculating single premiums.) **b **Adjustment on account of dividends to credit of policy . . . . . . 59b **c Total.**Add lines 59a and 59b . . . . . . . . . . . . . . . . . . . . . . . **d **Outstanding indebtedness against policy . . . . . . . . . . . . . . . . . . . **e **Net total value of policy (for gift or estate tax purposes). Subtract line 59d from line 59c . . . . |
58c | 58f | ||
| 58 If policy is not paid up: **a **Interpolated terminal reserve on date of death, assignment, or irrevocable designation of beneficiary . . . . . . . . . . . 58a **b **Add proportion of gross premium paid beyond date of death, assignment, or irrevocable designation of beneficiary . . . . . . . . . . . 58b **c **Add adjustment on account of dividends to credit of policy . . . . 58c **d Total.**Add lines 58a, b, and c . . . . . . . . . . . . . . . . . . . . . . . **e **Outstanding indebtedness against policy . . . . . . . . . . . . . . . . . . . **f ** Net total value of the policy (for gift or estate tax purposes). Subtract line 58e from line 58d . . . 59 If policy is either paid up or a single premium: **a ** Total cost, on date of death, assignment, or irrevocable designation of beneficiary, of a single-premium policy on life of insured at attained age, for original face amount plus any additional paid-up insurance (additional face amount ) . . . . . . . . 59a (If a single-premium policy for the total face amount would not have been issued on the life of the insured as of the date specified, nevertheless, assume that such a policy could then have been purchased by the insured and state the cost thereof, using for such purpose the same formula and basis employed, on the date specified, by the company in calculating single premiums.) **b **Adjustment on account of dividends to credit of policy . . . . . . 59b **c Total.**Add lines 59a and 59b . . . . . . . . . . . . . . . . . . . . . . . **d **Outstanding indebtedness against policy . . . . . . . . . . . . . . . . . . . **e **Net total value of policy (for gift or estate tax purposes). Subtract line 59d from line 59c . . . . |
58c | 59c | ||
| 58 If policy is not paid up: **a **Interpolated terminal reserve on date of death, assignment, or irrevocable designation of beneficiary . . . . . . . . . . . 58a **b **Add proportion of gross premium paid beyond date of death, assignment, or irrevocable designation of beneficiary . . . . . . . . . . . 58b **c **Add adjustment on account of dividends to credit of policy . . . . 58c **d Total.**Add lines 58a, b, and c . . . . . . . . . . . . . . . . . . . . . . . **e **Outstanding indebtedness against policy . . . . . . . . . . . . . . . . . . . **f ** Net total value of the policy (for gift or estate tax purposes). Subtract line 58e from line 58d . . . 59 If policy is either paid up or a single premium: **a ** Total cost, on date of death, assignment, or irrevocable designation of beneficiary, of a single-premium policy on life of insured at attained age, for original face amount plus any additional paid-up insurance (additional face amount ) . . . . . . . . 59a (If a single-premium policy for the total face amount would not have been issued on the life of the insured as of the date specified, nevertheless, assume that such a policy could then have been purchased by the insured and state the cost thereof, using for such purpose the same formula and basis employed, on the date specified, by the company in calculating single premiums.) **b **Adjustment on account of dividends to credit of policy . . . . . . 59b **c Total.**Add lines 59a and 59b . . . . . . . . . . . . . . . . . . . . . . . **d **Outstanding indebtedness against policy . . . . . . . . . . . . . . . . . . . **e **Net total value of policy (for gift or estate tax purposes). Subtract line 59d from line 59c . . . . |
58c | 59d | ||
| 58 If policy is not paid up: **a **Interpolated terminal reserve on date of death, assignment, or irrevocable designation of beneficiary . . . . . . . . . . . 58a **b **Add proportion of gross premium paid beyond date of death, assignment, or irrevocable designation of beneficiary . . . . . . . . . . . 58b **c **Add adjustment on account of dividends to credit of policy . . . . 58c **d Total.**Add lines 58a, b, and c . . . . . . . . . . . . . . . . . . . . . . . **e **Outstanding indebtedness against policy . . . . . . . . . . . . . . . . . . . **f ** Net total value of the policy (for gift or estate tax purposes). Subtract line 58e from line 58d . . . 59 If policy is either paid up or a single premium: **a ** Total cost, on date of death, assignment, or irrevocable designation of beneficiary, of a single-premium policy on life of insured at attained age, for original face amount plus any additional paid-up insurance (additional face amount ) . . . . . . . . 59a (If a single-premium policy for the total face amount would not have been issued on the life of the insured as of the date specified, nevertheless, assume that such a policy could then have been purchased by the insured and state the cost thereof, using for such purpose the same formula and basis employed, on the date specified, by the company in calculating single premiums.) **b **Adjustment on account of dividends to credit of policy . . . . . . 59b **c Total.**Add lines 59a and 59b . . . . . . . . . . . . . . . . . . . . . . . **d **Outstanding indebtedness against policy . . . . . . . . . . . . . . . . . . . **e **Net total value of policy (for gift or estate tax purposes). Subtract line 59d from line 59c . . . . |
58c | 59e |
The undersigned officer of the above-named insurance company (or appropriate federal agency or retirement system official) hereby certifies that this statement sets forth true and correct information.
Signature Title
Date of Certification
Form 712 (Rev. 12-2024)
Form 712 (Rev. 12-2024) Page 3
General Instructions¶
Section references are to the Internal Revenue Code unless otherwise noted.
Future Developments
For the latest information about developments related to Form 712 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/Form712 .
Specific Instructions¶
Statement of insurer. This statement must be made, on behalf of the insurance company that issued the policy, by an officer of the company having access to the records of the company.
For purposes of this statement, a facsimile signature may be used in lieu of a manual signature and if used, shall be binding as a manual signature. Separate statements. File a separate Form 712 for each policy. Line 13. Report on line 13 the annual premium, not the cumulative premium to date of death.
If death occurred after the end of the premium period, report the last annual premium.
Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. We collect this information under the authority under Internal Revenue Code section 6501(d). We need it to ensure that
you are complying with these laws and to allow us to figure and collect the right amount of tax. You are not required to request prompt assessment; however, if you do so, you are required to provide the information requested on this form. Failure to provide the information may delay or prevent processing your request. Section 6109 requires you to provide the requested taxpayer identification numbers.
You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential as required by section 6103.
The time needed to complete and file this form will vary depending on individual circumstances.
The estimated average time is: Recordkeeping . . . . . . . . . 18 hrs., 11 min. Learning about the form . . . . . . . . 6 min. Preparing the form . . . . . . . . . . 23 min. If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy to hear from you.
See the instructions for the tax return with which this form is filed. Do not send the tax form to that office. Instead, return it to the executor or representative who requested it.