IRS · Official form

Form 712, Life Insurance Statement

Form 712 is the statement an insurance company completes to document a life insurance policy’s value for estate and gift tax purposes. It is attached to Form 706, 706-NA, or 709 rather than filed on its own.

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What is 712?

Form 712 reports the details the IRS needs to value a life insurance policy in an estate or gift tax context: the insurer, policy number, face amount, premiums, and the amount paid at death or the policy’s value on the date of a gift. Part I covers policies on a decedent’s life that pay out at death, while Part II covers the value of a policy that was transferred during life or is owned by the decedent on someone else’s life.

The form is completed by the life insurance company that issued the policy, then attached by the executor or donor as supporting documentation. It substantiates the numbers reported on Schedule D of Form 706 or on Schedule A of Form 709, and examiners routinely expect to see one Form 712 per policy.

Who files 712?

Executors attaching policy documentation to an estate tax return, Form 706 or 706-NA
Donors who gave away a life insurance policy and are reporting the gift on Form 709
Life insurance companies completing the statement at the request of an executor or policy owner
Trustees of irrevocable life insurance trusts documenting a transferred policy’s value

How to fill out 712

Request the form from the insurer, or fill in the policy details here: insurer name, policy number, and the insured’s information.
For a policy paying out at death, complete Part I with the face amount, proceeds, and any accumulated dividends or outstanding loans.
For a gifted or third-party policy, complete Part II, which reports the interpolated terminal reserve and unearned premium that establish the value.
Have an officer of the insurance company sign the statement, since the insurer certifies the figures.
Download the PDF and attach one completed Form 712 per policy to the Form 706, 706-NA, or 709 it supports.

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Page 1 52 fields

1 Decedent’s first name and middle initial

2 Decedent’s last name

3 Decedent’s social security number (if known)

4 Date of death

5a Name of insurance company

5b Address (number and street) of insurance company

5c City

5d State

5e ZIP code

6 Type of policy

7 Policy number

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

9 Date issued

10 Assignor’s name. Attach copy of assignment.

11 Date assigned

12 Value of the policy at the time of assignment

13 Amount of premium (see instructions)

14 Name of beneficiaries

15. Face amount of policy.

16. Indemnity benefits.

17. Additional insurance.

18. Other benefits.

19. Principal of any indebtedness to the company that is deductible in determining net proceeds.

20. Interest on indebtedness (line 19) accrued to date of death.

21. Amount of accumulated dividends.

22. Amount of post-mortem dividends.

23. Amount of returned premium.

24. Amount of proceeds if payable in one sum.

25. Value of proceeds as of date of death (if not payable in one sum).

26. Policy provisions concerning deferred payments or installments. If other than a lump-sum settlement is authorized for a surviving

26. Policy provisions concerning deferred payments or installments.

27. Amount of installments.

28. Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. Row: 1. Column: (i) Name of

Row: 1. Column: (i i) Date of birth.

Row: 1. Column: (i i i) Sex.

Row: 2. Column: (i) Name of person the duration of whose life may measure beyond the number of payments.

Row: 2. Column: (i i) Date of birth.

Row: 2. Column: (i i i) Sex.

Row: 3. Column: (i) Name of person the duration of whose life may measure beyond the number of payments.

Row: 3. Column: (i i) Date of birth.

Row: 3. Column: (i i i) Sex.

29. Amount applied by the insurance company as a single premium representing the purchase of installment benefits.

30. Basis (mortality table and rate of interest) used by insurer in valuing installment benefits.

31. Were there any transfers of the policy within the 3 years prior to the death of the decedent? Yes.

3 years prior to the death of the decedent? No

Month Day Year

33. Was the insured the annuitant or beneficiary of any annuity contract issued by the company? Yes.

Was the insured the annuitant or beneficiary of any annuity contract issued by the company? No

34. 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

34. No.

35. Names of companies with which decedent carried other policies and amount of such policies if this information is disclosed by your

Title

Page 2 39 fields

36 First name and middle initial of donor (or decedent)

37 Last name

38 Social security number

39. Date of gift for which valuation data submitted.

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

41 Name of insured

42. Sex. 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

50 Frequency of payment

51 Assignee’s name

52 Date assigned

53 If irrevocable designation of beneficiary made, name of beneficiary

54. Sex. 54 Sex

55 Date of birth, if known

56 Date designated

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

58. If policy is not paid up: a. Interpolated terminal reserve on date of death, assignment, or irrevocable designation of beneficiary.

58b. Add proportion of gross premium paid beyond date of death, assignment, or irrevocable designation of beneficiary.

58c. Add adjustment on account of dividends to credit of policy.

58d. Total. Add lines 58a, b, and c.

58e. Outstanding indebtedness against policy.

58f. 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. Total cost, on date of death, assignment, or irrevocable designation of

59a. Amount.

59b. Adjustment on account of dividends to credit of policy.

59c. Total. Add lines 59a and 59b.

59d. Outstanding indebtedness against policy.

59e. Net total value of policy (for gift or estate tax purposes). Subtract line 59d from line 59c.

Title

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Frequently asked questions

Who actually fills out Form 712?

The insurance company that issued the policy completes and signs it, because the form certifies policy values from the insurer’s own records. The executor or donor requests it and attaches it to the estate or gift tax return.

Is Form 712 filed by itself?

No. It is an attachment, one per policy, supporting Form 706, 706-NA, or 709. It has no separate filing deadline beyond the due date of the return it accompanies.

Form 712, Life Insurance Statement

What is 712?

Who files 712?

How to fill out 712

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Frequently asked questions

Related forms

Form 706, United States Estate (and Generation-Skipping Transfer) Tax Return

Form 706-NA, United States Estate (and Generation-Skipping Transfer) Tax Return for Nonresident Aliens

Form 709, United States Gift (and Generation-Skipping Transfer) Tax Return