Policyholders - Unclaimed Property

Please complete the information below based on the unclaimed funds letter you received.

Please choose an option

I am claiming funds that belong to myself or my business
I am claiming funds based on an individual who is deceased
I am claiming funds on an individual who is not myself and is still living

Payee Name

Check Amount

Check #

Check Issue Date

I am not entitled to the above referenced funds or these funds have already been paid to me
I am entitled to and wish to claim the above reference property (select direct deposit or check below).
I am aware of these funds and choose not to claim them at the present time due to:

Reissue by Direct Deposit - Checking Account Only (not valid for Medicare Supplement, U-Haul Retiree and Indemnity Plans)
Reissue by Check.

Please indicate the address to issue the check to below.

Address

City

State

Zip Code

Home Phone

Individual Claiming Fund

Relationship to Payee

Name on Account

Routing #

Account Number

Enter code that is on the bottom right hand corner of letter.

I, the requester of these funds, warrant the truthfulness of the information provided above. I agree any funds claimed and deposited erroneously may be debited back out of my account by your company.

Electronic Signature