Please download Adobe Reader® 9.0 to view the form.
We are providing downloadable claim forms as a convenience to our policyholders and beneficiaries. Obtaining a claim form through this site will not constitute notice of a death or a claim. We cannot accept claim forms online; therefore, you will need to mail us the completed claim form along with other requirements.
Deferred Annuity Claim Form
Once you download the claim form, you may type your information directly onto the form. After the claim form has been filled out and printed, be sure to sign it with blue or black ink. If you have any questions while filling out this form, please call:
Monday – Thursday 8:30 AM – 8 PM ET and Friday 9AM – 8PM ET
Please mail the following documents to the address below:
- The entire original contract. (If the original is lost, a signed claim form will allow us to begin processing.)
- A separate signed, dated and fully completed claim form for each beneficiary.
- An original, raised seal certified death certificate indicating the final cause of death. Only one original death certificate per deceased person is required.
Annuity Claims Department
3100 Albert Lankford Drive
P.O. Box 1572
Lynchburg, VA 24505-1572
We may require other documents depending on the specific circumstances of your claim. Please see the section on the form labeled Special Claimant Instructions for more information.