Change Of Ownership Page 2
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1
2BENEFICIARY INFORMATION
If_you_are_designating_more_than_one_beneficiary,_complete_the_Additional_Beneficiary_Designation_section_below._In_accordance_with_
the_provisions_of_the_contract,_I/we_revoke_all_former_beneficiary_designations_and_elect_to_change_the_beneficiary_as_indicated_below._
Additional_beneficiaries_may_be_designated_on_a_separate_sheet_and_must_include_a_signature_on_each_page.
Name____________________________________________________________ _ Social_Security_Number______________________
Relationship_ _______________________________________ _ Date_of_Birth_______________________ _ Percentage___________
Address______________________________________________________________________________________________________
City__________________________________________________________________ _ State_ _ ________ Zip_ __________________
ADDITIONAL BENEFICIARY DESIGNATION
_ Primary_
_ Contingent
Name____________________________________________________________ _ Social_Security_Number______________________
Relationship_ _______________________________________ _ Date_of_Birth_______________________ _ Percentage___________
Address______________________________________________________________________________________________________
City__________________________________________________________________ _ State_ _ ________ Zip_ __________________
_ Primary_
_ Contingent
Name____________________________________________________________ _ Social_Security_Number_ _ ______________________
Relationship_ _______________________________________ _ Date_of_Birth_______________________ _ Percentage___________
Address______________________________________________________________________________________________________
City__________________________________________________________________ _ State_ _ ________ Zip_ __________________
If_beneficiary_will_be_a_trust,_complete_the_following:
_ Primary_
_ Contingent
Name_of_Trust_____________________________________________________ _ Social_Security/Tax_ID_Number_ _ ________________
Trustee’s_Name____________________________________________________ _ Date_of_Trust_ _______________________________
Address______________________________________________________________________________________________________
City__________________________________________________________________ _ State_ _ ________ Zip_ __________________
GUIDELINES
You_the_contract_owner,_understand_and_agree_that:
_ Joint_owners_are_considered_equal_owners_of_the_contract._Either_owner_may_exercise_any_ownership_rights_in_the_contract.
_ The_Company_is_furnishing_this_form_and_is_participating_in_this_transaction_at_your_request._The_Company_has_no_responsibility_nor_
_ liability_for_the_validity_of_this_change_of_ownership_nor_liability_for_the_tax_treatment_to_the_owner(s).
_ The_Company_will_report_the_contract_value_at_the_time_of_the_ownership_change_to_the_Internal_Revenue_Service_on_Form_1099-R_or_other
_ appropriate_form(s)_unless_the_change_concerns_spouses,_is_incident_to_a_divorce,_or_involves_adding_or_deleting_a_contingent_owner.
AUTHORIZATION AND SIGNATURES
By_signing_below,_you_certify_that_you_have_read,_understand,_and_agree_to_the_Guidelines_section_and_authorize_the_Company_to_implement_
these_changes_to_your_contract.
_______________________________________________________________________________ _ ___________________________
Current_Contract_Owner’s_Signature_
Date
_______________________________________________________________________________ _ ___________________________
Current_Joint_Contract_Owner’s_Signature_(if_applicable)_
Date
_______________________________________________________________________________ _ ___________________________
Witness’_Signature_
Date
_______________________________________________________________________________ _ ___________________________
New_Contract_Owner’s_Signature_
Date
_______________________________________________________________________________ _ ___________________________
New_Joint_Contract_Owner’s_Signature_(if_applicable)_
Date
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