Fillable Non-Financial Service Request Form printable pdf download

Regular Mail to:

Overnight Mail to:

Great-West Life & Annuity Insurance

Company of New York

Attn: RROC

PO Box 173921

8515 E Orchard Road 8T2

Denver, CO 80217-3920

Greenwood Village, CO 80111

Phone: (800) 905-1959

Non-Financial Service Request Form

Owner Name _________________________________________________

Group __________________________________

Owner

Annuity

Social Security No._____________________________Ext ____________

Number _________________________________

Owner Address:

Street _______________________________________________________

City___________________ State________ Zip _______________

Owner Phone Numbers:

Daytime ____________________________________________________

Evening ________________________________



Change of Address

Change Annuitant Name

Name change of Owner (Ownership Change see below)

From:

Name and Address

To :

Name and Address

Reason For Change:_____________________________________________ Effective Date of Change _________________________

Supporting Documentation

□ a legible certified or notarized copy of valid Government issued photo ID with a current dated signature is attached

□ legal documentation for any name changes is attached (i.e. copy of marriage license, divorce decree, trust extract, etc)



(Non-qualified Contracts Only)  Add Joint Annuitant*

Remove Joint Annuitant*

Change of Annuitant*

I (we), the present Owner(s) of the above numbered policy, hereby revoke any previous designation of annuitant and hereby designate as the

annuitant of the said policy effective in accordance with the policy provision, the following:

Annuitant Social Security Number:_____________________ Date of Birth____________Relationship to Owner________________________

Full Name:_______________________________________________________________________________________________________

First

Middle

Last

Address : _________________________________________________________________________________________________________

Street

City

State

Zip



(Non-qualified Contracts Only)

Add Joint Owner*

Remove Joint Owner*

Change of Ownership*

I (we), the present Owner(s) of the above numbered policy, hereby revoke any previous designation of owner and hereby designate as the

owner of the said policy effective in accordance with the policy provision, the following:

Owner Social Security or Taxpayer ID Number:__________________ Date of Birth__________Relationship to Owner___________________

Full Name:________________________________________________________________________________________________________

First

Middle

Last

Address:

________________________________________________________________________________________________________________

Street

City

State

Zip

Supporting Documentation:

If ownership is changing to a trust a notarized copy of either the Trust or an Affidavit of Trust form is attached. Also, for each trustee,

attached is a legible notarized copy of Government issued photo id including a current dated signature.

If ownership is changing to an individual a legible certified or notarized copy of valid Government issued photo Identification is attached.

Notes:

•

If you transfer ownership of this policy to a minor, you should be aware that no changes can be made to the policy until the minor

attains the age at which he or she acquires the capacity to contract for such annuity.

•

This change of ownership is not a change of beneficiary or annuitant. The present designation of beneficiary, annuitant and method of

payment will remain in effect unless changed by the new owner during the lifetime of the annuitant.

•

This transfer of ownership shall take effect immediately and shall automatically revoke any previous designation.

GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY OF NEW YORK

The principal underwriter is GWFS Equities, Inc., a wholly owned subsidiary of Great-West Life & Annuity Insurance Company and an

affiliate of Great-West Life & Annuity Insurance Company of New York.

Non-Financial Service Request Form

Last Updated 01/16

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Non-Financial Service Request Form

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