Common use of PART I – CLAIMANT INFORMATION Clause in Contracts

PART I – 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. Co-Beneficial Owner Name Address 1 (Street Name and Number) Xxxxxxx 0 (xxxxxxxxx, xxxx, xx box number) City State ZIP Foreign Province Foreign Country Telephone Number (home) Telephone Number (work) Email Address Account Number (if filing for multiple accounts, file a separate Claim Form for each account) Social Security Number (for individuals): OR Taxpayer Identification Number (for estates, trusts, corporations, etc.): Claimant Account Type (check appropriate box): Individual (includes joint owner accounts) Pension Plan Trust Corporation Estate XXX/401K Other (please specify)

PART I – 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. Co-Beneficial Owner Name Address 1 (Street Name and Number) Xxxxxxx 0 (xxxxxxxxx, xxxx, xx box number) City State ZIP Foreign Province Foreign Country Telephone Number (home) Telephone Number (work) Email Address Account Number (if filing for multiple accounts, file a separate Claim Form for each account) Social Security Number (for individuals): OR Taxpayer Identification Number (for estates, trusts, corporations, etc.): Claimant Account Type (check appropriate box): Individual (includes joint owner accounts) Pension Plan Trust Corporation Estate XXX/401IRA/401K Other (please specify)

PART I – 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. Co-Beneficial Owner Name Address 1 (Street Name and Number) Xxxxxxx 0 Address 2 (xxxxxxxxxapartment, xxxxunit, xx or box number) City State ZIP Foreign Province Foreign Country Telephone Number (home) Telephone Number (work) Email Address Account Number (if filing for multiple accounts, file a separate Claim Form for each account) Social Security Number (for individuals): OR Taxpayer Identification Number (for estates, trusts, corporations, etc.): Claimant Account Type (check appropriate box): Individual (includes joint owner accounts) Pension Plan Trust Corporation Estate XXX/401IRA/401K Other (please specify)