Guardian Trust Certification Form
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1
2THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA
Customer Service Office
THE GUARDIAN INSURANCE & ANNUITY COMPANY, INC.
3900 Burgess Place
BERKSHIRE LIFE INSURANCE COMPANY OF AMERICA
Bethlehem, PA 18017
(Please check appropriate company. In this form, “the Company”
is the insurer checked above.)
TRUST CERTIFICATION
1. Policy Information ̶ Proposed Insured(s)/Insured(s)
Policy Number(s) ________________________________________________________________________________________
LIFE ONE
LIFE TWO
1.
Name ________________________________________
2.
Name _______________________________________
First
Middle
Last
First
Middle
Last
2. Trust Information
1.
Name of Trust _______________________________________________________________________________________
2.
a) Name(s) of Trustee(s) _______________________________________________________________________________
b) Nature of the relationship between the Grantor(s) and the Trustee(s) __________________________________________
c) Duration of the relationship ___________________________________________________________________________
3.
Tax Identification Number of Trust _______________________________________________________________________
Applied for (Check this box if you have applied for a number and are waiting for one to be issued.
You have 60 days to submit a certified TIN in order to avoid backup withholding.)
4.
Is this a Grantor Trust?
Yes
No
Please consult with a tax advisor to determine whether your Trust is a Grantor Trust (as described in Sections 671–679
of the Internal Revenue Code).
If 'Yes', please provide:
Grantor’s TIN or SSN: __________________
Grantor’s Date of Birth: ___________________
Month
Day
Year
5.
Transaction requests must be authorized by (Select one.):
Any one Trustee
All Trustees
A majority of Trustees
6.
Who are the current Beneficiaries of the Trust? _____________________________________________________________
7.
a) Effective Date of Trust ______________________
b) Date Trust was signed/executed ________________________
Month
Day
Year
Month
Day
Year
c) Situs of Trust: The Trust is subject to the laws of the State of _______________________________________________
8.
Address of Trust _____________________________________________________________________________________
Street No. & Name
Suite No.
City
State
Zip code
9.
Did you retain an attorney to prepare the Trust document?
Yes
No
(We will not contact the attorney without
your written approval.)
If 'Yes', provide name and address of attorney. If 'No' provide name and address of person who provided Trust document.
Name of Attorney/Provider _____________________________________________________________________________
Address of Attorney/Provider ___________________________________________________________________________
Street No. & Name
Suite No.
City
State
Zip code
TRUST-CERT-2011 (9/14)
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