Trust Certification Form
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2Banner Life Insurance Company
3275 Bennett Creek Avenue
Frederick, Maryland 21704
TRUST CERTIFICATION
(800) 638-8428
Section 1
Purpose of this Form
This form is used for situations where a Trust is the owner or the beneficiary of the life insurance policy issued by our Company. The Trustee(s)
should complete and execute this form.
Section 2
General Information
Proposed Insured name _______________________________________________
Name of Trust ______________________________________________________
State where created __________________ Date Trust created __________________ Tax ID #________________________
• If a living Trust, then the Tax ID may be the same as the grantor’s SSN.
Section 3
Type of Trust (check all boxes that apply)
Trust is:
o Revocable Trust
o Testamentary Trust under the last will and testament of ______________________________
o Irrevocable Trust
Date of death ____________________
Date will was executed _____________________
AND
Trust is:
o Family Trust
o Trusteed Buy/Sell
o Charity Trust
o Insurance Trust
o Employer Sponsored Trust
o Other type of Trust_________________________
Section 4
Grantor(s)
Identification information of the Grantor/Settlor(s) who established the Trust:
Name _____________________________________________________________________________________________
Address _______________________________________ City, State, Zip _______________________________________
Name _____________________________________________________________________________________________
Address _______________________________________ City, State, Zip _______________________________________
Section 5
Beneficiary(ies)
Names and relationships of the beneficiaries of the Trust:
Name ________________________________________
Relationship to Proposed Insured/Insured ______________________
Name ________________________________________
Relationship to Proposed Insured/Insured ______________________
Name ________________________________________
Relationship to Proposed Insured/Insured ______________________
Section 6
Trustee(s)
For multiple Trustees ONLY, please print the names of all Trustees and check one of the following boxes (if no box is checked, the Company
will require all signatures on all policy requests).
o A majority may act for all
o All must act unanimously
o Anyone may act alone
o Certain trustees must act jointly (print names below)
Trustee #1 ________________________ Trustee #2 ________________________ Trustee #3 _______________________
Note: If the Insurance Producer is a Trustee, please provide the reason and relationship of that individual to the insured.
o Immediate family member or
o Other _______________________________
Reason _____________________________________________________________________________________________
LU-1277 (02/09)
Page 1
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