Annuity

Used to accept Update II (2) for dividends on a policy.

To request full or partial 1035 exchange of policy or contract to a new policy or contract issued by Nassau Life Insurance Company.

Used to request a partial withdrawal from annuity contracts. The form includes the Federal/State Income Tax Withholding Election (OL4753) and Withholding Certificate for Periodic Pension or Annuity Payments (W-4P).

Used to surrender annuity contracts. The form includes the Federal/State Income Tax Withholding Election (OL4753) and Withholding Certificate for Periodic Pension or Annuity Payments (W-4P).

Used to setup reoccurring partial withdrawals from annuity contracts. The form includes the Federal/State Income Tax Withholding Election (OL4753) and Withholding Certificate for Periodic Pension or Annuity Payments (W-4P).

Additional form needed for policy change/rate reduction (PartIIRateReduction).

Used to request a policy change requiring underwriting. This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Alaska (AL). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Arizona (AZ). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for California (CA). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Connecticut (CT). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Florida (FL). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Georgia (GA). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Hawaii (HI). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Idaho (ID). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Indiana (IN). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Louisiana (LA) and Nevada (NV). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Massachusetts (MA). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Maryland (MD). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Maine (ME). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Minnesota (MN). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Missouri (MO). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Montana (MT). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for North Carolina (NC). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Nebraska (NE). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for New Hampshire (NH). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for New Mexico (NM). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for New York (NY). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Ohio (OH). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Oklahoma (OK). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Oregon (OR). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Pennsylvania (PA). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Puerto Rico (PR). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for South Carolina (SC). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Texas (TX). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Utah (UT). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Virginia (VA). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Vermont (VT). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Washington (WA). This form includes the Privacy Notice (OL4042).

Used to request a policy change requiring underwriting for Wisconsin (WI). This form includes the Privacy Notice (OL4042).

Used for assigning a policy as collateral for a loan.

Used to change or update beneficiary(ies) on a life policy or annuity contract.

Used to update beneficiary(ies) on a life policy or annuity contract (PCA)

Used to obtain a Beneficiary or Claimant’s statement to support a death claim on Life policy.

Used to obtain a Beneficiary or Claimant’s statement to support a death claim on an Annuity contract for residents in Alaska, Florida, Kansas, Minnesota, New Hampshire, and New York.

Used to obtain a Beneficiary or Claimant’s statement to support a death claim on an Annuity contract. The form includes the Federal/State Income Tax Withholding Election (OL4753) and Withholding Certificate for Periodic Pension or Annuity Payments (W-4P).

Used to obtain a Beneficiary or Claimant’s statement to support a death claim on an Annuity contract for Alaska, Florida, Kansas, Minnesota, New Hampshire, and New York. The form includes the Federal/State Income Tax Withholding Election (OL4753) and Withholding Certificate for Periodic Pension or Annuity Payments (W-4P).

Used to request a loan on a policy or contract.

Applicable to beneficiaries residing in foreign countries.

Used to certify that the specified individual is authorized to enter legally binding transactions on behalf of a company.

Used to certify and acknowledge a trust on a policy or contract (New Business).

Used to request a death claim settlement for a trust on a policy or contract.

Used to request a death claim settlement for a trust on a policy or contract for Jackson National Life Insurance Company

Used to certify and acknowledge a trust on a policy or contract for title and client relations (Existing Business).

Request to change the annuitant and or joint annuitant on a contract.

Used to submit or update a name change on a life policy or annuity contract.

Used to setup a bank draft on a policy or contract.

Used to setup a bank draft (premium payment, premium deposit fund, or loan repayment) on a policy or contract.

Used to add a collateral assignment to a policy.

PCA Concierge Account with Signature for a supplemental contract.

Used to verify the insured’s death that occurred in a foreign country on a claim.

Used to designate individual(s) as new owner(s) on a policy or contract.

Used to designate a non-individual as new owner and beneficiary on a policy or contract.

Used to designate a trust as new owner and beneficiary on a policy or contract.

Request direct deposit of payments on a life policy or annuity contract.

Used to authorize the release of non-medical information on a policy/contract to a third party.

Used to apply/authorize dividends to pay balance of premium becoming due by release of paid-up additions.

Plan disclosure and agreement of pension trusts and profit sharing.

Used to update or change federal and state tax withholding elections. The form includes the Withholding Certificate for Periodic Pension or Annuity Payments (W-4P).

Use to request history of all policy account transactions for a specified period of time.

Used to request a full surrender of a policy or contract for FLIAC. The form includes the Federal/State Income Tax Withholding Election (OL4753), Withholding Certificate for Periodic Pension or Annuity Payments (W-4P), and Direct Deposit (OL4020).

Used to request a full surrender of a policy or contract for FLIAC. The form includes the Federal/State Income Tax Withholding Election (OL4753), Withholding Certificate for Periodic Pension or Annuity Payments (W-4P), and State of Oregon notice (HO5190ORA).

Used to request a full surrender of a policy or contract for FLIAC. The form includes the Federal/State Income Tax Withholding Election (OL4753), Withholding Certificate for Periodic Pension or Annuity Payments (W-4P), Direct Deposit (OL4020), and State of Washington notices (HO5232WA and HO5270WA).

Used for reinstatement or rate reduction purposes. Insured’s authorization to release medical information for all states except KS, MA, ME, MN, NM, and VT.

Used for reinstatement or rate reduction purposes. Insured’s authorization to release medical information for residents in Kansas (KS).

Used for reinstatement or rate reduction purposes. Insured’s authorization to release medical information for residents in Massachusetts (MA).

Used for reinstatement or rate reduction purposes. Insured’s authorization to release medical information for residents in Maine (ME).

Used for reinstatement or rate reduction purposes. Insured’s authorization to release medical information for residents in Minnesota (MN).

Used for reinstatement or rate reduction purposes. Insured’s authorization to release medical information for residents in New Mexico (NM).

Used for reinstatement or rate reduction purposes. Insured’s authorization to release medical information for residents in Vermont (VT).

An IRA settlement option notice for beneficiaries required to take distributions from an inherited contract.

To process a request for Qualified Charitable Distribution as defined in Internal Revenue Code section 408(d)(8).

Form 712 is filed by executors with Form 706, 706-NA, or 709 for insurance policy or premium amounts.

This affidavit is used to list the children of the insured on a life insurance policy

Used to surrender life policies. The form includes the Federal/State Income Tax Withholding Election (OL4753) and Withholding Certificate for Periodic Pension or Annuity Payments (W-4P).

To request a duplicate contract if the original contract has been lost, misplaced, or destroyed.

This certificate is issued upon request by the Owner that the original policy has been lost or destroyed.

Worksheet used for major medical expense.

Used for matured variable contract settlement annuitization options.

Use to request money from outside company

A nonqualified settlement option notice for beneficiaries required to take distributions from an inherited contract.

TAMRA (MEC) Modified Endowment Contract sign off form for a life policy.

Used to designate a second person to receive correspondences regarding lapse or termination on a policy due to non-payment of premium. This form accompanies the Required State Notices (HO5238 or MEGA form) being sent to CA resident/issue state policy holders.

Notice to policy owner regarding the change or remitted premium will be treated as Modified Endowment Contract (MEC).

To request changes on Optionterm coverage.

Used to request a partial surrender or withdrawal request of a contract. The form includes the Direct Deposit (OL4020), Federal/State Income Tax Withholding Election (OL4753) and Withholding Certificate for Periodic Pension or Annuity Payments (W-4P).

Used to request a partial surrender or withdrawal request of a contract for Oregon. The form includes the Direct Deposit (OL4020), Federal/State Income Tax Withholding Election (OL4753) and Withholding Certificate for Periodic Pension or Annuity Payments (W-4P).

Used to request a partial surrender or withdrawal request of a contract for Washington. The form includes the Direct Deposit (OL4020), Federal/State Income Tax Withholding Election (OL4753) and Withholding Certificate for Periodic Pension or Annuity Payments (W-4P).

To grant third party (partner) authorization on a policy(ies).

A summary of payment options notice for legacy annuity contracts.

Plan disclosure and agreement of pension trusts.

Used to certify a (POA) Attorney-in-Fact.

Used to verify policy account information.

This Privacy Statement applies to the collection, use, and disclosure of information from and about the client in order to offer the client products and services, determine the qualification of products and services, and account administration. This form is mailed with annual or anniversary statements, end-of-year statements for “F” annuity contracts (LifeComm), lapses notices (if lapse occurred more than a year prior to the last policy anniversary).

Used to request reinstatement of a policy. This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Alaska (AK). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Arizona (AZ). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for California (CA). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Connecticut (CT). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Florida (FL). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Georgia (GA). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Hawaii (HI). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Indiana (IN). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Kansas (KS). This form includes the HIPAA for KS (OL4076KS) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Louisiana (LA). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Massachusetts (MA). This form includes the HIPAA for MA (OL4076MA) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Maryland (MD). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Maine (ME). This form includes the HIPAA for ME (OL4076ME) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Michigan (MI). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Minnesota (MN). This form includes the HIPAA for MN (OL4076MN) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Missouri (MO). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for North Carolina (NC). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Nebraska (NE). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for New Jersey (NJ). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for New Mexico (NM). This form includes the HIPAA for NM (OL4076NM), Privacy Notice (OL4042), and Notice of Confidential Abuse Information New Mexico Regulation (OL3061).

Used to request reinstatement of a policy for New York (NY). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Ohio (OH). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Oklahoma (OK). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Oregon (OR). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Pennsylvania (PA). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Puerto Rico (PR). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for South Carolina (SC). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Texas (TX). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Utah (UT). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Virginia (VA). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Vermont (VT). This form includes the HIPAA for VT (OL4076VT) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Washington (WA). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to request reinstatement of a policy for Wisconsin (WI). This form includes the HIPAA (OL4076) and Privacy Notice (OL4042).

Used to release/relinquish the right, title, and interest of an assignee on a life policy or annuity contract.

Used to request an address change on a life policy or annuity contract for the owner, annuitant, assignee, or recipient of a duplicate notice.

Used to change a life insurance policy to a paid-up policy.

Used to request a contract change from a FIVA A to FIVA C (Tax Tamer I).

Used to postpone maturity date of an annuity contract.

Used to request a change to information or instructions on a policy.

Used to make changes on a policy (face decrease, rate reductions, conversion).

Used to request a change to information or instructions on a policy for residents in Arizona, Nevada, New Mexico, Texas, Washington, and Wisconsin.

Used to request a change to information or instructions on a policy for residents in California (CA).

Used to request a change to information or instructions on a policy for residents in Idaho (ID).

Used to request a change to information or instructions on a policy for residents in Louisiana (LA).

Used to request a change to information or instructions on a policy for residents in Missouri (MO).

To request Split-Dollar forms and servicing on a policy.

Request for systematic withdrawal prior to annuitization. The form includes the Direct Deposit (OL4020), Federal/State Income Tax Withholding Election (OL4753) and Withholding Certificate for Periodic Pension or Annuity Payments (W-4P).

Used to correct/update beneficiary SSN/TIN.

Used to request required minimum distribution (RMD). The form includes the Federal/State Income Tax Withholding Election (OL4753), Withholding Certificate for Periodic Pension or Annuity Payments (W-4P), and Direct Deposit (OL4020).

Used to request required minimum distribution (RMD) for HomeComm fixed annuities. The form includes the Federal/State Income Tax Withholding Election (OL4753) and Withholding Certificate for Periodic Pension or Annuity Payments (W-4P).

MEGA form mailed out with correspondences related to annual, semi-annual, and anniversary statements regardless of resident state or issue state. Form is only required to be mailed to policy holders issued in or live in CA, ID, NH, NM, NJ, VT, RI, and WI. Use in RI and WI for annuities.

(PCA) Concierge Account settlement option disclosure for claims.

Used to request money from outside company as an IRA Transfer or IRA Rollover.

Used for maturity annuitization settlement option. The form includes the Federal/State Income Tax Withholding Election (OL4753), Withholding Certificate for Periodic Pension or Annuity Payments (W-4P), and Direct Deposit (OL4020).

Used for maturity annuitization settlement option for FLIAC. The form includes the Annuitization Options (ARF), Federal/State Income Tax Withholding Election (OL4753), Withholding Certificate for Periodic Pension or Annuity Payments (W-4P), and Direct Deposit (OL4020).

Used to add a spilt dollar assignment to a policy.

Request to substitute the original annuitant/owner with the designated spousal beneficiary to continue the contract of an IRA or qualified plan.

Request to substitute the original annuitant/owner with the designated spousal beneficiary to continue the contract of a non-qualified plan.

New Jersey specific tax form required by NJ division of taxation for claim payments to non-spousal beneficiaries.

Rhode Island specific tax form, required by RI division of taxation for claims payments being made in excess of $50,000.

Used in annual 1099 Stuffer – FAQs.

Trade/fund change form used to request changing subaccounts on variable products (Insured Series policy 12 Pay only, Tax Tamer I, and Tax Tamer II).

Trade/fund change form used to request changing subaccounts on variable products (ISP Choice, Single Premium, Variable Universal, First Choice, and First Choice Bonus)

Trade/fund change form used to request or discontinue systematic transfer of subaccounts on variable products (ISP Choice, Single Premium, Variable Universal, First Choice, and First Choice Bonus).

Smoking statement to apply for non-smoking rates or non-smoker and never smoke risk classification.

To be completed by the attending physician for a disability claim.

Used for submitting an Accidental Death Benefit Rider claim

Request to surrender a single or annual premium paid up additions rider.

Used to request a full surrender of a policy or contract. The form includes the Federal/State Income Tax Withholding Election (OL4753) and Withholding Certificate for Periodic Pension or Annuity Payments (W-4P).

Used to request a full surrender of a policy or contract. The form includes the Federal/State Income Tax Withholding Election (OL4753), Withholding Certificate for Periodic Pension or Annuity Payments (W-4P), and State of Oregon notice (HO5190ORA).

Used to request a full surrender of a policy or contract. The form includes the Federal/State Income Tax Withholding Election (OL4753) and Withholding Certificate for Periodic Pension or Annuity Payments (W-4P), and State of Washington notices (HO5232WA and HO5270WA).

VA cover letter to accompany a request of a 1035 exchange or transfer form OL4378.

Submit the IRS Form W-4R nonperiodic withholding certificate to change the Federal income tax default rate for a one-time payment, distribution, or withdrawal.

Submit the IRS Form W-4P periodic withholding certificate to change the Federal income tax default rate for a periodic payment, distribution, or withdrawal.