Tax Form 712 Fill in and Calculate Online

Form 712: Life Insurance Statement

Use Tax Form 712: Life Insurance Statement as a stand alone tax form calculator to quickly calculate specific amounts for your 2024 tax return. Alternatively you can use one of our Combined Federal and State Tax Estimator to quickly calculate your salary, tax and take home pay.

Life Insurance Statement
Part I 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.)
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
5	Name and address of insurance company
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					15	$
16	Indemnity benefits					16	$
17	Additional insurance					17	$
18	Other benefits					18	$
19	Principal of any indebtedness to the company that is deductible in determining net proceeds					19	$
20	Interest on indebtedness (line 19) accrued to date of death.					20	$
21	Amount of accumulated dividends					21	$
22	Amount of post-mortem dividends					22	$
23	Amount of returned premium					23	$
24	Amount of proceeds if payable in one sum					24	$
25	Value of proceeds as of date of death (if not payable in one sum)					25	$
26	Policy provisions concerning deferred payments or installments. Note. If other than lump-sum settlement is authorized for a surviving spouse, attach a copy of the insurance policy.
27	Amount of installments					27	$
28	Date of birth, sex, and name of any person the duration of whose life may measure the number of payments.
29	Amount applied by the insurance company as a single premium representing the purchase of installment benefits					29	$
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 three years prior to the death of the decedent?						Yes No
32	Date of assignment or transfer:
33	Was the insured the annuitant or beneficiary of any annuity contract issued by the company?						Yes No
34	Did the decedent have any incidents of ownership on any policies on his/her life, but not owned by him/her at the date of death?						Yes No
35	Names of companies with which decedent carried other policies and amount of such policies if this information is disclosed by your records.
Part II Living Insured (File with Form 709, United States Gift (and Generation-Skipping Transfer) Tax Return. 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	38	Social security number
39	Date of gift for which valuation data submitted ▸
40	Date of decedent’s death for which valuation data submitted ▸
SECTION B—Policy Information
41	Name of insured			42	Sex	43	Date of birth
44	Name and address of insurance company
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	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			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.					58d
e	Outstanding indebtedness against policy					58e
f	Net total value of the policy (for gift or estate tax purposes). Subtract line 58e from line 58d					58f
59	If policy is either paid up or a single premium:
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 $) (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.)			59a
b	Adjustment on account of dividends to credit of policy			59b
c	Total. Add lines 59a and 59b					59c
d	Outstanding indebtedness against policy					59d
e	Net total value of policy (for gift or estate tax purposes). Subtract line 59d from line 59c					59e

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