21134GO (4/2020)
2
Agent or Registered Representative Assignment Request Form continued
▫
Temporary Servicing Agent
To qualify as a Temporary Servicing Agent (TSA), please have the client sign this form (cannot be solicited by mail), and return to your
*HQHUDO2ƯFHIRUSURFHVVLQJ3OHDVHQRWHD76$DVVLJQPHQWZLOOH[SLUHDIWHUPRQWKVLIWKH76$GRHVQRWPHHWDGGLWLRQDOFULWHULD
UHTXLUHGWREHFRPHD3HUPDQHQW6HUYLFLQJ$JHQW1RQHZSDSHUZRUNLVQHHGHGWRH[WHQGD76$LIWKH0DQDJLQJ3DUWQHUDSSURYHV$
TSA assignment can be revoked at any time at the discretion of the Managing Partner. TSA assignments are not available for registered
SURGXFWV/7&Ƭ[HGDQQXLWLHVRU%2/,&2/,
Criteria Required Documentation
▫
Client has no active agent Form 21134GO
▫
Permanent Servicing Agent
This section is not required if the policy owner is requesting the assignment of a Servicing Agent/Registered Representative on a
UHJLVWHUHGSURGXFW/7&SURGXFWƬ[HGDQQXLW\RU%2/,&2/,SURGXFWDQGKDVVLJQHGSDJHRIWKH$JHQWRU5HJLVWHUHG5HSUHVHQWDWLYH
Assignment Request Form.
7RTXDOLI\DVD3HUPDQHQW6HUYLFLQJ$JHQW36$RQDSURGXFWRWKHUWKDQDUHJLVWHUHGSURGXFW/7&SURGXFWƬ[HGDQQXLW\RU%2/,&2/,
product, please select one of the following criteria and submit the required documentation:
Criteria Required Documentation
▫
6DOHWRH[LVWLQJKRXVHKROG )LUVWSDJHRIDSSOLFDWLRQ
▫
An increase or decrease in face amount First page of application
▫
An increase or decrease in premium, including adding an OPP rider First page of application
▫
$GGLQJUHPRYLQJRUH[HUFLVLQJDULGHU )LUVWSDJHRIDSSOLFDWLRQ
▫
Completing a Transfer or Interest Sweep Form 18523 or 18485
▫
Change in future allocation or automatic reallocation
Form 18485 or 21130
for a variable annuity or variable life policyholder
▫
&KDQJLQJDEHQHƬFLDU\ )RUP
▫
Delivering a death claim to a member of the household Form 20838A
▫
Processing a waiver of premium for a member of the household Form 22030
▫
Processing a transfer of ownership Form 21132
Securities are offered through by properly licensed registered representatives of NYLIFE Securities LLC (member FINRA/SIPC),
a Licensed Insurance Agency, 51 Madison Avenue, New York NY 10010.
Please select one assignment request:
Managing Partner’s Signature Date
0DQDJLQJ3DUWQHUoVVLJQRƪ
X
21134GO 0420 02