Fillable Form Fptpafm - Third Party Authorization printable pdf download

Third Party Authorization

Introduction

Instructions

Use this form to authorize another person or entity, called a “Third Party,” to receive documents and information related to your

individual annuity contract or certificate under a group annuity contract with John Hancock Life Insurance Company (U.S.A.) or

John Hancock Life Insurance Company of New York (together, “John Hancock”). This form is not a power-of-attorney and does not

authorize the Third Party to conduct withdrawals or other transactions. If you own or participate in more than one contract, insert all

applicable numbers in Section 1. Additionally, if your contract has a joint owner or joint participant, his or her information must be

included in Section 1 and he or she must sign in Section 4. All signatures must be notarized or Medallion Guaranteed.

NO CROSS OUTS, WHITE OUTS, MARGINAL NOTATIONS, OR OTHER CHANGES OR ADDITIONS WILL BE ACCEPTED.

Questions about this form?

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for return instructions

1-800-824-0335

FAX 1-617-663-3160

1. Contract Information (Owner or Participant)

Contract Number

Certificate/Customer Number(s) (if applicable)

Owner or Participant Phone Number

Owner or Participant Date of Birth (MM/DD/YYYY)

Owner or Participant Name (First)

(MI)

(Last)

Owner or Participant Address (Street)

City

State

Zip

Co-Owner or Joint Participant Name (if applicable)

Co-Owner or Joint Participant Phone Number

Date of Birth (MM/DD/YYYY)

Co-Owner or Joint Participant Address (Street)

City

State

Zip

2. Authorized Third Party Name and Contact Information

Name (First)

(MI)

(Last)

Address (Street)

City

State

Zip

Relationship to Owner or Participant

Phone Number

Date of Birth (MM/DD/YYYY)

3. Authorization Agreement and Release of Liability

¡ Contract Documents and Information. I authorize John Hancock to provide, upon request, any and all documents and information

in its possession related to the individual annuity contract or certificate under a group annuity contract identified in Section 1 to the

Third Party identified in Section 2.

¡ Personal Information. I authorize John Hancock to provide, upon request, my non-public personal information, including, but not

limited to, Social Security number, date of birth, medical records, phone number, physical address and email address to the Third

Party identified in Section 2.

¡ Delivery Method. I authorize John Hancock to provide, upon request, documents and information to the Third Party by any delivery

method, including traditional mail, overnight carrier, email, facsimile and on the phone.

¡ Entities. If the Third Party is a law firm, accounting firm, bank, credit union, government agency, financial institution or other entity,

this authorization shall include any agent, employee, attorney, officer or other representative purporting to act on behalf of such entity.

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FPTPAFM (5/16)

Form Fptpafm - Third Party Authorization

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