Form 712 Life Insurance Statement

712

Life Insurance Statement

Form
(Rev. December 2024)
Department of the Treasury
Internal Revenue Service

Part I
1

OMB No. 1545-0022

Go to www.irs.gov/Form712 for the latest information.

Decedent—Insured

(To be filed by the executor with Form 706, United States Estate (and Generation-Skipping Transfer) Tax Return, or Form 706-NA, United
States Estate (and Generation-Skipping Transfer) Tax Return, Estate of nonresident not a citizen of the United States.)

Decedent’s first name and
middle initial

2

5a Name of insurance company
6

Type of policy

8

Owner’s name. If decedent is not
owner, attach copy of application.

Decedent’s last name

3

Decedent’s social security 4
number (if known)

5b Address (number and street) of
insurance company

5c City
7

9

5d State 5e ZIP code

Policy number

10 Assignor’s name. Attach copy of
assignment.

Date issued

11 Date assigned

12

Value of the policy at
13 Amount of premium
the time of assignment
(see instructions)

15
16
17
18
19
20
21
22
23
24
25
26

Face amount of policy
. . . . . . . . . . . . . . . . . . . . . . . . .
Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . .
Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . .
Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Principal of any indebtedness to the company that is deductible in determining net proceeds . .
Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . .
Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . .
Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . .
Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . .
Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . .
Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . .
Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement
is authorized for a surviving spouse, check here and attach a copy of the insurance policy . . .

15
16
17
18
19
20
21
22
23
24
25

27
28

Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . .
Date of birth, sex, and name of any person the duration of whose life may measure the number of
payments.

27

14 Name of beneficiaries

(i) Name of person the duration of whose life may measure
beyond the number of payments

29

(ii) Date of birth

(iii) Sex

30

Amount applied by the insurance company as a single premium representing the purchase of
installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . .
Basis (mortality table and rate of interest) used by insurer in valuing installment benefits.

31
32

Were there any transfers of the policy within the 3 years prior to the death of the decedent?
If you checked “Yes” on line 31, enter date of assignment or transfer:
/
/
Month

33
34
35

Date of death

Day

.

.

29

.

.

.

Yes

No

Year

Was the insured the annuitant or beneficiary of any annuity contract issued by the company? . . . . .
Yes
No
Did the decedent have any incidents of ownership on any policies on the decedent’s life, but not owned by
the decedent at the date of death? . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
Names of companies with which decedent carried other policies and amount of such policies if this information is disclosed by
your records.

The undersigned officer of the above-named insurance company (or appropriate federal agency or retirement system official) hereby certifies that this statement sets forth
true and correct information.

Signature

Date of
Certification

Title

For Privacy Act and Paperwork Reduction Act Notice, see instructions.

Cat. No. 10170V

Form 712 (Rev. 12-2024)

Page 2

Form 712 (Rev. 12-2024)

Part II

Living Insured

(File with Form 709, United States Gift (and Generation-Skipping Transfer) Tax Return, and Form 709-NA, United States Gift (and
Generation-Skipping Transfer) Tax Return on Nonresident Not a Citizen of the United States. May also be filed with Form 706, United
States Estate (and Generation-Skipping Transfer) Tax Return, or Form 706-NA, United States Estate (and Generation-Skipping Transfer)
Tax Return, Estate of nonresident not a citizen of the United States, where decedent owned insurance on life of another.)

SECTION A—General Information
36

First name and middle initial of donor (or decedent)

37 Last name

39
40

Date of gift for which valuation data submitted
. . . . .
Date of decedent’s death for which valuation data submitted .

41

Name of insured

.
.

38 Social security number
.
.

.
.

.
.

.
.

.
.

.
.

.
.

.
.

39
40

.
.

SECTION B—Policy Information
42 Sex

43 Date of birth

44a Name of insurance company

44b Address (number and street) of
insurance company

44c City

44d State 44e ZIP code

45

Type of policy

46 Policy number

47 Face amount

48 Issue date

49

Gross premium

51

Assignee’s name

53

If irrevocable designation of beneficiary made, name of
beneficiary

57

If other than simple designation, quote in full. Attach additional sheets if necessary.

50 Frequency of payment
52 Date assigned
54 Sex

55 Date of birth,
if known

56 Date designated

58

If policy is not paid up:
Interpolated terminal reserve on date of death, assignment, or
irrevocable designation of beneficiary . . . . . . . . . . . 58a
b Add proportion of gross premium paid beyond date of death, assignment,
or irrevocable designation of beneficiary . . . . . . . . . . . 58b
c Add adjustment on account of dividends to credit of policy . . . . 58c
d Total. Add lines 58a, b, and c . . . . . . . . . . . . . . . . . . . . .
e Outstanding indebtedness against policy . . . . . . . . . . . . . . . . .
f Net total value of the policy (for gift or estate tax purposes). Subtract line 58e from line 58d .
59
If policy is either paid up or a single premium:
a

.
.
.

.
.
.

58d
58e
58f

.
.
.

.
.
.

59c
59d
59e

a

Total cost, on date of death, assignment, or irrevocable designation of
beneficiary, of a single-premium policy on life of insured at attained
age, for original face amount plus any additional paid-up insurance
(additional face amount
) . . . . . . . . 59a
(If a single-premium policy for the total face amount would not have
been issued on the life of the insured as of the date specified,
nevertheless, assume that such a policy could then have been
purchased by the insured and state the cost thereof, using for such
purpose the same formula and basis employed, on the date specified,
by the company in calculating single premiums.)
b Adjustment on account of dividends to credit of policy . . . . . . 59b
c Total. Add lines 59a and 59b . . . . . . . . . . . . . . . . . . . .
d Outstanding indebtedness against policy . . . . . . . . . . . . . . . .
e Net total value of policy (for gift or estate tax purposes). Subtract line 59d from line 59c .

.
.
.

The undersigned officer of the above-named insurance company (or appropriate federal agency or retirement system official) hereby certifies that this statement sets forth
true and correct information.

Signature

Title

Date of
Certification
Form 712 (Rev. 12-2024)

Form 712 (Rev. 12-2024)

General Instructions
Section references are to the Internal Revenue Code
unless otherwise noted.

Future Developments
For the latest information about developments related to
Form 712 and its instructions, such as legislation enacted
after they were published, go to www.irs.gov/Form712.

Specific Instructions
Statement of insurer. This statement must be made, on
behalf of the insurance company that issued the policy,
by an officer of the company having access to the
records of the company.
For purposes of this statement, a facsimile signature
may be used in lieu of a manual signature and if used,
shall be binding as a manual signature.
Separate statements. File a separate Form 712 for each
policy.
Line 13. Report on line 13 the annual premium, not the
cumulative premium to date of death.
If death occurred after the end of the premium period,
report the last annual premium.
Privacy Act and Paperwork Reduction Act Notice. We
ask for the information on this form to carry out the
Internal Revenue laws of the United States. We collect
this information under the authority under Internal
Revenue Code section 6501(d). We need it to ensure that

Page 3

you are complying with these laws and to allow us to
figure and collect the right amount of tax. You are not
required to request prompt assessment; however, if you
do so, you are required to provide the information
requested on this form. Failure to provide the information
may delay or prevent processing your request. Section
6109 requires you to provide the requested taxpayer
identification numbers.
You are not required to provide the information
requested on a form that is subject to the Paperwork
Reduction Act unless the form displays a valid OMB
control number. Books or records relating to a form or its
instructions must be retained as long as their contents
may become material in the administration of any Internal
Revenue law. Generally, tax returns and return
information are confidential as required by section 6103.
The time needed to complete and file this form will
vary depending on individual circumstances.
The estimated average time is:
Recordkeeping . . . . . . . . . 18 hrs., 11 min.
Learning about the form . . . . . . . .
6 min.
Preparing the form . . . . . . . . . . 23 min.
If you have comments concerning the accuracy of
these time estimates or suggestions for making this form
simpler, we would be happy to hear from you.
See the instructions for the tax return with which this
form is filed. Do not send the tax form to that office.
Instead, return it to the executor or representative who
requested it.