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New York Life Insurance CompanyGroup Membership Association ClaimsPO Box 30782Tampa FL 33630-3782(800) 792-9686Dear Beneficiary:Please accept our condolences on your recent loss. We understand this is a difficult time, and we hope thatwe can alleviate any concerns you may have about your claim.New York Life Insurance Company is providing the enclosed Claim Form for your convenience. Pleasereview the form in its entirety, and then follow the step-by-step instructions to submit your claim.New York Life Insurance Company prides itself on the speed with which it pays claims. Please return thecompleted Claim Form, death certificate and any additional documents that we may request, so we canprocess your benefit promptly. *Please be assured that New York Life will act as quickly as possible to complete the processing of your claimonce we receive all the necessary information and documentation. Please feel free to contact your planadministrator, if you have any questions.Sincerely,Kathleen ScollanVice President and CFOCLAIM FORM FOR LIFEINSURANCE PROCEEDS*New York Life reserves the right to determine whether any insurance was in force at the time of death and to whom theproceeds are payable.DCF20201203

HOW TO COMPLETE YOUR CLAIM FORMPlease read this before you start to complete your Claim FormTo facilitate the processing of your claim, please send us a fully completed Claim Form from each beneficiary, one deathcertificate and any other documents that we may request. You may use a photocopy of the Claim Form if there is more thanone beneficiary. No original documents will be returned.GROUP CERTIFICATE INFORMATIONPlease be sure to enter all certificate numbers on the Claim Form and enclose all the original insurance certificates, if available.If not available, please explain.DECEASED INFORMATIONInformation about the deceased is necessary for purposes of identification and benefit determination.BENEFICIARY INFORMATIONInformation about the Beneficiary is necessary for claims processing.Taxpayer Identification Number: Life insurance benefits are generally not subject to income tax. However, New York Lifepays interest on all proceeds from the date of death. Since the interest paid to you may be taxable, you should consult your taxadvisor.The Federal government requires us, and all other financial institutions, to report interest we pay you. Therefore, we are requiredto obtain your Social Security Number or Taxpayer Identification Number, which you must certify under penalties of perjury. Ifyou are applying for a tax number, please write, “applied for” in the appropriate space. If you fail to supply us with an identificationnumber, the Federal government requires us to withhold a portion of your interest as a deposit against the taxes that may bedue.Some persons have been notified by the Internal Revenue Service that they are subject to “backup withholding” because in thepast they did not report all their interest or dividends. If you have been so notified, and a backup withholding order has not beenrescinded, you must check the Backup Withholding statement right below your Income Tax Certification. We may contact youfor more information if there are any questions about your Taxpayer Identification Number or backup withholdings status, or ifyou are a non-resident alien or foreign entity. Claims by an Estate: If an Executor or Administrator is filing the claim, he or she must sign the Claim Form andsubmit a certified copy of the appointment papers. Be sure to use the Tax Identification Number of the Estate.Note: A Last Will and Testament will not be accepted as proof of authority of executorship. Assignment: If you have assigned all or any portion of the claim to a funeral home for final expenses, pleaseinclude a copy of that assignment. If the deceased assigned the policy proceeds to a bank or other financialinstitution, an authorized representative of that institution must sign the Claim Form. If the Beneficiary is a Minor: If there is a legal guardian for a minor, he or she should sign the Claim Form andsubmit a copy of the court document appointing the custodian of the minor child’s property/estate. If no legalguardian has been appointed, payment may be considered under the Uniform Transfers to Minors Act (UTMA)subject to state guidelines. Please contact our office for further information.Payment Option for Death Benefit ProceedsPayment will be made by check. For individual beneficiaries (a person claiming on their own behalf) Electronic Funds Transfer(EFT) is available. If you would like to have the funds payable by EFT you will need to submit a copy of your voided check orvoided savings slip along with your completed claim form. With the EFT option, you will receive an Explanation of Benefitsmailed to your home address. If for any reason we are not able to process the EFT payment will be made by check.YOUR SIGNATUREPlease sign the Claim Form.MEDICAL INFORMATION AND AUTHORIZATIONComplete this section ONLY IF all or any portion of life insurance coverage was issued within two years of the death of theinsured, or if you are making a claim for an Accidental Death Benefit.Illinois Interest StatementIf the certificate was issued in Illinois, you will be paid 10% interest, from the date of death, if your claim is not paid within 31days of receiving the necessary proof needed to settle the claim.DCF20201203

State Variations of Fraud WarningsPlease refer to the applicable fraud warnings for your state of residenceArizona For your protection Arizona law requires the following statement to appear on this form. Any person who knowinglypresents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.California For your protection California law requires the following to appear on this form: Any person who knowingly presents afalse or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.Colorado It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for thepurpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance andcivil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleadingfacts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimantwith regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurancewithin the Department of Regulatory Agencies.District of Columbia Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowinglypresents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.Florida Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or anapplication containing any false, incomplete, or misleading information is guilty of a felony of the third degree.Maryland Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or whoknowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines andconfinement in prison.New Jersey Any person who knowingly files a statement of claim containing any false or misleading information is subject tocriminal and civil penalties.New York Any person who knowingly and with the intent to defraud any insurance company or other person files an application forinsurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, informationconcerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penaltynot to exceed five thousand dollars and the stated value of the claim for each such violation.Oregon Any person who knowingly and with intent to defraud any insurance company or other person files an application forinsurance or statement of claim containing any materially false information or conceals for the purpose of misleading, informationconcerning any fact material thereto may be subject to prosecution for insurance fraud. Any person who provides misinformationmaterial to the content of the contract, which is relied upon by the insurer, and which is either material to the risk assumed by theinsurer or provided fraudulently, may be subject to the denial of insurance benefits.Pennsylvania Any person who knowingly and with intent to defraud any insurance company or other person files an applicationfor insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, informationconcerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal andcivil penalties.Puerto Rico Any person who knowingly and with the intention of defrauding presents false information in an insurance application,or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents morethan one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation withthe penalty of a fine of not less than five thousand dollars ( 5,000) and not more than ten thousand dollars ( 10,000), or a fixedterm of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the penalty thusestablished may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to aminimum of two (2) years.Other States Any person who knowingly and with the intent to defraud any insurance company or other person files an applicationfor insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading,information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person tocriminal and civil penalties. Penalties may include imprisonment, fines, or a denial of insurance benefits if a person provides falseinformation.DCF20201203

CLAIM FORM Please type or print clearly.Please return this Claim Form together with the death certificate and any other documentation that we may request to the addressthe Plan Administrator has provided to you.LIST ALL GROUP CERTIFICATE NUMBERS UNDER WHICH YOU ARE MAKING A CLAIMAre the Group Certificates attached?YesNoDECEASED INSURED INFORMATIONMonthManner of Death:NaturalLostOtherNickname orMaiden Name:Name:Date of BirthIf no, please explainDayYearSuicide*Accident*Date of DeathMonthHomicide*DayUnknown*Please attach copies of police and coroner’s report and any relevant news articles.YearOtherBENEFICIARY INFORMATIONName:Address:Home Phone:FirstMiddleStreetLastCity()Alternate Phone:Date of Birth:MonthStateDay(Zip Code)Email Address(Required):YearSocial Security or Taxpayer Identification Number:In what capacity are you making this claim?BeneficiaryExecutorTrusteeOtherRelationship to Deceased:SpouseChildParentOtherYOUR SIGNATUREI have read and understand the fraud warning in the “State Variations of Fraud Warnings” applicable to the state in which I reside. New YorkResidents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statementof claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commitsa fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of theclaim for each such violation.Under penalties of perjury, I certify: (1) My Social Security Number or Tax ID shown on this form is my correct taxpayer identification number, (2) I amnot subject to backup withholding because (a) I am exempt from backup withholding; or (b) I have not been notified by the IRS that I am subject tobackup withholding as a result of a failure to report all interest or dividend income; or (c) the IRS has notified me that I am no longer subject to backupwithholding, (3) I am a U.S. person (includes a U.S. resident alien), and (4) The (FATCA) code entered on this form (if any) indicating that I am exemptfrom FATCA reporting is correct. (Please note: if being submitted for a U.S. account, this last certification (4) does not apply.)Check this box if the IRS has notified you that you are subject to backup withholding.If you are not a U.S. citizen, U.S. resident alien or other U.S. person, you must submit the applicable Form W-8 with this form to certify your foreignstatus and, if applicable, claim treaty benefits.If you are not a U.S. person, your signature below only applies to the provisions of this document other than the provisions contained in this OwnerTax Certification section.The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required toavoid backup withholding.Signature (Required)DCF20201203Date

MEDICAL INFORMATION AND AUTHORIZATIONHIPAA-Compliant AuthorizationTo expedite the processing of your claim, please complete this page in its entirety.Complete if(a) the death occurred within two years of the issue date or reinstatement date,(b) the death was due to an accident and the policy contains the Accidental Death Benefit, or(c) if specifically requested.Physician /Doctor NameAddress, City, State, Zip CodeTelephone NumberDatesConditionMEDICAL AUTHORIZATION:I give my permission to release information concerning who died onName of Insuredto New York Life Insurance Company including its agents, affiliates or subsidiary companies and attorneys, reinsurers, insurance support groups andindependent administrators who are acting on their behalf (“New York Life”). Information released may include records of medical advice, medical care,medical treatment of AIDS or AIDS-related diseases, mental illness, drug or alcohol use, other insurance coverage, financial and employment history,driving records, or information otherwise needed to determine policy claim benefits due but excludes psychotherapy notes. This information may bereleased by medical professionals or facilities, pharmacies, pharmacy benefit managers, government offices, employers, insurance companies,insurance support groups, group policyholders or benefit plan administrators, any consumer reporting agency, the Social Security Administration, theInternal Revenue Service, the Veteran’s Administration, or any other organization or person having any knowledge of the above-named Insured. Whenrequesting information from any of the sources named above, a copy of this form is as valid as the original. I am aware that any information obtainedwill be used to evaluate my claim.Either I, or a person I choose, am entitled to receive a copy of this authorization. This authorization is valid from the date signed until the claim isresolved, except in those states that allow for only a one-year limit.I have the right to revoke this authorization at any time by notifying New York Life in writing at the address on this authorization. My revocation will notbe effective to the extent New York Life or any other person already has disclosed or collected information or taken other action in reliance on thisauthorization. My revocation will also not be effective to the extent state law gives New York Life the right to contest a claim under the policy or thepolicy itself.The information New York Life obtains based on this authorization may be subject to further disclosure. For example, New York Life may be requiredto provide it to insurance regulatory or other government agencies. In this case, the information may no longer be protected by the rules governing thisauthorization.SignatureDCF20201203Relationship to InsuredDate

New York Life Insurance Company is providing Claim Form for your convenience. Please the enclosed review the form in its entirety, and then follow the step-by-step instructions to submit your claim. New York Life Insurance Company prides itself