Fillable Certification Of Trust Agreement Form printable pdf download

CERTIFICATION OF TRUST AGREEMENT

CLEAR FORM

Please complete using information from the Trust document

Policy / Contract No(s)

: ________________________ _______________________ ______________________

*Please state pending if this form is being submitted with a new application.

Name of Annuitant(s)/Insured: ___________________________________________________________________

First Name

Last Name

____________________________________________________________________

First Name

Last Name

Full Name of Trust: _____________________________________________________________________________

Trust Effective Date: ____ /____ /________ Trust Identification Number / Tax ID Number: ________________________

Which state law governs this Trust? ________________________________________________________________

Relationship of Trust to the Annuity Policy/Contract: (Please mark the appropriate box.)

❑ Owner

❑ Beneficiary

❑ Both Owner and Beneficiary

Preparer of Trust: __________________________________ Preparer’s Telephone Number: _____ - _____ - ________

Preparer’s Address: ____________________________________________________________________________

Street

City

State

Zip

Name of Grantor(s)/Settlor(s)

: ___________________________________________________________________

First Name

Last Name

___________________________________________________________________

First Name

Last Name

Name/Address of Trustee(s):____________________________________________________________________

First Name

Last Name

_________________________________________________________________________________________

Street

City

State

Zip

____________________________________________________________________

First Name

Last Name

________________________________________________________________________________________

Street

City

State

Zip

Name/Address of Successor Trustee(s):______________________________________________________________

First Name

Last Name

________________________________________________________________________________________

Street

City

State

Zip

_____________________________________________________________________

First Name

Last Name

________________________________________________________________________________________

Street

City

State

Zip

1. The above referenced Trust Agreement (the “Trust”) requires that: (Please mark the appropriate box.)

❑ all Trustees

❑ a majority of Trustees

❑ any Trustee

❑ Trust only has one Trustee

Must sign documents pertaining to the above-referenced Policy/Contract(s) which require a signature.

2. The insurance agent or any person affiliated with the insurance agent is not a beneficiary of the above referenced trust.

❑ Agree

❑ Disagree

If marked disagree, please attach an explanation of why your agent or person affiliated with your agent is named as a beneficiary of the trust.

Note: Under the laws of most states, an agent is restricted in, or prohibited from, having a beneficial interest in a contract sold by that agent, unless that agent is

a family member, or has a recognized insurable interest. Additionally, North American company policy prohibits our agents from serving in any capacity that may be con-

strued as creating a direct or indirect conflict of interest with regard to a contract or contracts for which they are or have been the agent(s) of record.

3. The relationship of the Trust Beneficiary(ies) to the Annuitant/Insured is:

❑ Spouse

❑ Children

❑ Grandchildren

❑ Other________________________

4. Was the Trust validly executed, and is it in full force and effect?

❑ Yes ❑ No

5. Will a trust be named as the Owner or Beneficiary of this contract/policy?

❑ Yes ❑ No

If YES, answer question 6.

NORTh AMERICAN FOR LIFE AND hEALTh INSURANCE

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