2017 Dividend Payee Form

2017 DIVIDEND PAYEE FORM

Please complete both pages of the letter below and email it to Sherri Pitre at (preferred), fax it to 504.841.5301 or mail it to LAMMICO, attention: Sherri Pitre. Please note that only forms submitted via email will receive a confirmation of receipt.

All forms must be received in our office by February 1, 2018 in order for your request to be processed.

LAMMICO

Attn: Finance Department

One Galleria Blvd., Suite 700

Metairie, LA 70001

Re: Dividend Checks

Dear LAMMICO:

The insured signatures on Page 2 indicate their agreement to disburse their dividend payments declared December 6, 2017 and to be issued in March of 2018 to:

______

[Requested payee name]

The Federal Tax ID # for this payee is: ______

Please send the check to the following address: ______

______

The telephone number for the above-named payee is: ______

Sincerely,

______

Print Name

______

Signature

______

Title

______

Email Address

2017 DIVIDEND PAYEE FORM

Page 2

I agree that my LAMMICO dividend declared December 6, 2017 and to be issued in March of 2018

be issued to: ______

[Requested payee name]

______