Common use of CLAIMANT INFORMATION Clause in Contracts

CLAIMANT INFORMATION. The Claims Administrator will use this information for all communications regarding this Claim Form. If this information changes, you MUST notify the Claims Administrator in writing at the address above. Complete names of all persons and entities must be provided. Beneficial Owner’s Name First Name Last Name Joint Beneficial Owner’s Name (if applicable) First Name Last Name If this claim is submitted for an XXX, and if you would like any check that you MAY be eligible to receive made payable to the XXX, please include “XXX” in the “Last Name” box above (e.g., Xxxxx XXX). Entity Name (if the Beneficial Owner is not an individual) Name of Representative, if applicable (executor, administrator, trustee, c/o, etc.), if different from Beneficial Owner Last 4 digits of Social Security Number or Taxpayer Identification Number Street Address City State/Province Zip Code Foreign Postal Code (if applicable) Foreign Country (if applicable) Telephone Number (Day) Telephone Number (Evening) Email Address (email address is not required, but if you provide it you authorize the Claims Administrator to use it in providing you with information relevant to this claim): Specify one of the following: Individual(s) Corporation UGMA Custodian XXX Partnership

CLAIMANT INFORMATION. The Claims Administrator will use this information for all communications regarding this Claim Form. If this information changes, you MUST notify the Claims Administrator in writing at the address above. Complete names of all persons and entities must be provided. Beneficial Owner’s Name First Name Last Name Joint Beneficial Owner’s Name (if applicable) First Name Last Name If this claim is submitted for an XXX, and if you would like any check that you MAY be eligible to receive made payable to the XXX, please include “XXX” in the “Last Name” box above (e.g., Xxxxx XXX). Entity Name (if the Beneficial Owner is not an individual) Name of Representative, if applicable (executor, administrator, trustee, c/o, etc.), if different from Beneficial Owner Last 4 digits of Social Security Number or Taxpayer Identification Number Street Address City State/Province Zip Code Foreign Postal Code (if applicable) Foreign Country (if applicable) Telephone Number (Day) Telephone Number (Evening) Email Address (email address is not required, but if you provide it you authorize the Claims Administrator to use it in providing you with information relevant to this claim): ) Specify one of the following: Individual(s) Corporation UGMA Custodian XXX PartnershipPartnership Estate Trust Other (describe: )

CLAIMANT INFORMATION. The Claims Administrator will use this information for all communications regarding this Claim Form. If this information changes, you MUST notify the Claims Administrator in writing at the address above. Complete names of all persons and entities must be provided. Beneficial Owner’s Name First Name Last Name Joint Beneficial Owner’s Name (if applicable) First Name Last Name If this claim is submitted for an XXX, and if you would like any check that you MAY be eligible to receive made payable to the XXX, please include “XXX” in the “Last Name” box above (e.g., Xxxxx XXX). Entity Name (if the Beneficial Owner is not an individual) Name of Representative, if applicable (executor, administrator, trustee, c/o, etc.), if different from Beneficial Owner Last 4 digits of Social Security Number or Taxpayer Identification Number Street Address City State/Province Zip Code Foreign Postal Code (if applicable) Foreign Country (if applicable) Telephone Number (Day) Telephone Number (Evening) Email Address (email address is not required, but if you provide it you authorize the Claims Administrator to use it in providing you with information relevant to this claim): ) Specify one of the following: Individual(s) Corporation UGMA Custodian XXX PartnershipPartnership Other (describe: )

CLAIMANT INFORMATION. The Claims Administrator will use this information for all communications regarding this Claim Form. If this information changes, you MUST notify the Claims Administrator in writing at the address above. Complete names of all persons and entities must be provided. Beneficial Owner’s Name First Name Last Name Joint Beneficial Owner’s Name (if applicable) First Name Last Name If this claim is submitted for an XXXIRA, and if you would like any check that you MAY be eligible to receive made payable to the XXXIRA, please include “XXX” in the “Last Name” box above (e.g., Xxxxx XXX). Entity Name (if the Beneficial Owner is not an individual) Name of Representative, if applicable (executor, administrator, trustee, c/o, etc.), if different from Beneficial Owner Last 4 digits of Social Security Number or Taxpayer Identification Number Street Address City State/Province Zip Code Foreign Postal Code (if applicable) Foreign Country (if applicable) Telephone Number (Day) Telephone Number (Evening) Email Address (email address is not required, but if you provide it you authorize the Claims Administrator to use it in providing you with information relevant to this claim): Specify one of the following: Individual(s) Corporation UGMA Custodian XXX PartnershipIRA Partnership Estate Trust Other (describe: )