Have you received notice of a class action? Yes No

If so, was the notice regarding a life insurance policy?  Yes No

If so, what life insurance company? N/A Allstate American General CIGNA Conneticut General Crown Life Equitable of Iowa Farm Bureau General American Life Great West Hartford Life IDS Life Insurance Company Jackson National Life John Hancock Metlife Metropolitan Life National Life of Vermont Nationwide New England Mutual Life New York Life Ins. Co. Northwestern Mutual Life Pacific Life Phoenix Home Life Principle Life Insurance Company Prudential State Farm State Mutual Sun Life and Transamerica Transamerica Accidental Life Ins. Co.

Did you purchase the life insurance during the period 1980-1999? Yes No

If so, What year? N/A 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

How did you purchase the life insurance?
Company Agent Independent Agent

Did the Life insurance policy in question replace a prior policy? Yes No

What is your name:

What is your email address: e.g. you@aol.com

Address:

City: State: Select Alabama Alaska Alberta American Samoa Arizona Arkansas Armed Forces Europe Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Province du Quebec Puerto Rico Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory

Zip: County:

Phone Number: Fax:

Additional Information

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If you prefer to give this information by phone, please call 1-800-365-1121