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, Middle, Last) Joint Beneficial Owner’s Name (First, Middle, Last) (if applicable) 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 🞎 IRA 🞎 Partnership 🞎 Estate 🞎 Trust 🞎 Other (describe):