New York Life Group Benefit Solutions (NYL GBS) Survivor Assurance If your insurance benefit is $5,000 or more, NYL GBS will automatically open a free, interest-bearing account in your name. This account, called the NYL GBS Survivor Assurance, is a convenient and secure place to keep your proceeds while you decide how to best use them. Please review the attached NYL GBS Survivor Assurance Disclosure Notice for full details about the account.* Account balances are the liability of the insurance company and are not insured by the Federal Deposit Insurance Corporation or any federal agency. The insurance company reserves the right to reduce account balances for any payment made in error. If your life insurance benefit is less than $5,000, NYL GBS will send you a check for the total benefit amount. *Please read the NYL GBS Survivor Assurance Disclosure Notice before signing below. I understand that if my benefit is $5,000 or more, I will receive a NYL GBS Survivor Assurance account. I understand that I may write a draft for the total amount in my account at any time. I understand that the account balance may be reduced for any benefit payment by the insurance company made in error. I acknowledge that, if I do not separately sign the NYL GBS Survivor Assurance Section of this Claim Form, I am not participating in the NYL GBS Survivor Assurance and that I will receive a single lump sum check for the proceeds due if my claim is approved. Signature* Date *Please sign as you would sign on a check, as signature may be used for draft verification. The issuance of this form is not an admission of the existence of any insurance nor does it recognize the validity of any claim and is without prejudice to the company’s legal rights. Beneficiary: Please complete and return to the Employer or New York Life Group Benefit Solutions. Page 3 of 9 LMS-613500 Revised 10/2023