Payment Instruction Form

Discretionary lump sum benefit

This form is for individuals claiming a discretionary lump sum benefit.

Payment number

Deceased's full name

Please read carefully:

We will pay the benefit to a beneficiary of the person named above who died on Date of Death.

We have identified that you are the rightful beneficiary of the person named above and we have not been made aware of any other

potential beneficiaries. We may ask you to repay the full amount, and any associated costs, if we find that there are other beneficiaries

you have not told us about who may be entitled to this benefit.

Beneficiary's details

Title

Forenames

Surname

Date of birth

Full address

Post code

Contact number

Relationship

Bank/building society details

Name of bank / building society

Account holder name

Sort code

Account number

Building society roll number

Only required if your bank has issued one to you.

Enclosures

Please upload copies of any supporting documentation as requested in our recent letter i.e. Passport, Marriage Certificate, Death Certificate, Bank Statement.

Drag and drop or choose a file

Add file

Declaration

Beneficiary's confirmation

I confirm that all the details provided above are correct and I am happy for you to proceed accordingly.

Today's date

Data privacy

For information on how we use your data please read the L&G Privacy Notice.

If you have any questions about completing this form please contact us on:

0345 0263858

Monday to Friday 9am to 5pm.
Calls may be monitored and recorded.