Form 3575 - Annuity Service Request Form
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1
2
3Annuity Service Request Form
Issued by American National Insurance Company
One Moody Plaza, Galveston, TX 77550-7999
Mailing Address: PO Box 696763 San Antonio, TX 78269 Phone Number: 1-800-252-9546 Fax: (409) 766-2022
page 1 of 3
POLICY NUMBER: _____________________________________________
ANNUITANT:_________________________________________
Note: The existing owner and joint owner (if applicable) must authorize all changes or requests by providing their signature in Section 8.
1. CHANGE OF NAME: Only complete this section if the annuitant, owner, or beneficiary’s name has changed.
Please complete section 3 for a Change of Annuitant, section 4 for a Change of Ownership,
or section 5 for a Change of Beneficiary.
Annuitant
Owner
Beneficiary
Current Name: ______________________________________________
New Name: _________________________________________________
Reason for Change:
Marriage
Divorce
Court Order
Correction
Other:__________________________
2. CHANGE OF ADDRESS:
Annuitant
Owner
Beneficiary
Old Address:
New Address:
____________________________________________________
____________________________________________________
Mailing Address
Mailing Address
__________________________________________________________
__________________________________________________________
City
State
Zip
City
State
Zip
3. CHANGE OF ANNUITANT: Only applies to contracts where a death benefit is not paid upon annuitant’s death.
I/We hereby request that the annuitant be changed:
From:_______________________________________________
To: _________________________________________________
SSN
TIN
EIN _____________________________
SSN
TIN
EIN ______________________________
Date of Birth:_________________________________________
Date of Birth:_________________________________________
____________________________________________________
____________________________________________________
Mailing Address
Mailing Address
____________________________________________________
____________________________________________________
City
State
Zip
City
State
Zip
4. CHANGE OF OWNERSHIP:
Complete this section to change the Owner:
Existing Owner’s Information:
New Owner’s Information:
Name:_________________________________________________
Name: _______________________________________________
SSN
TIN
EIN ________________________________
SSN
TIN
EIN _______________________________
Date of Birth:____________________________________________
Date of Birth: _________________________________________
_______________________________________________________
_____________________________________________________
Mailing Address
Mailing Address
_______________________________________________________
_____________________________________________________
City
State
Zip
City
State
Zip
Complete this section to change and/or add a Co-Owner:
Existing Co-Owner’s Information (if Co-Owner is changing):
New Co-Owner’s Information:
Name:_________________________________________________
Name: _______________________________________________
SSN
TIN
EIN ________________________________
SSN
TIN
EIN _____________________________
Date of Birth:____________________________________________
Date of Birth: _________________________________________
_______________________________________________________
_____________________________________________________
Mailing Address
Mailing Address
_______________________________________________________
_____________________________________________________
City
State
Zip
City
State
Zip
Note: A change in ownership may result in adverse tax consequences. Consult your tax advisor for guidance.
Form 3575
AMERICAN NATIONAL INSURANCE COMPANY
AMERICAN NATIONAL INSURANCE COMPANY
AMERICAN NATIONAL INSURANCE COMPANY
RV
RV
12-09
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