21134GO (4/2020)
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New York Life Insurance Company
New York Life Insurance and Annuity Corporation
(A Delaware Corporation)
51 Madison Avenue, New York, NY 10010
NYLIFE Insurance Company of Arizona
(Not licensed in every state)
4343 North Scottsdale Road, Suite 220
Scottsdale, AZ 85251
Agent or Registered Representative Assignment Request Form
STEP
2 Agent/Registered Representative (RR) Assignment and Policy owner and Agent/RR Signatures
Please assign Agent/Registered Representative
(please print name)
as servicing agent, and if also a registered representative of NYLIFE Securities LLC., as a registered representative on the policy number(s) above.
The assignment of a registered product policy must be to a Registered Representative of NYLIFE Securities, LLC. The assigned Agent/Registered
Representative must be properly licensed, registered (if applicable) and appointed in the customer’s state of residence. This request replaces all
previous requests.
Residential address for individual policy owners. Please provide applicable address for Trust/Corporate policyowners.
STREET APT. CITY S TAT E ZIP
Preferred phone # Email
Policy number(s)
FIRST M.I. LAST
Policy owner name, address, other contact information
Trust/Corporate name (if applicable)
STEP
1
Tell us your policy information. Please print the required information.
Insured/Annuitant’s name ,IGHUHQWWKDQSROLF\RZQHU Other insured’s name (for Survivorship plans)
FIRST M.I. LAST FIRST M.I. LAST
Continued on the next page
Agent/Registered Representative address
STREET APT. CITY S TAT E ZIP
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Title of Officer Name
Policy owner/Officer/Trustee Signature (if applicable) (Print) Date
Title of Officer Name
Policy owner (required if joint owner) Officer/Trustee Signature (if applicable) (Print) Date
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Agent/Registered Representative Signature Name (print) Date
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21134GO 0420 01
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21134GO (4/2020)
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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
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TSA assignment can be revoked at any time at the discretion of the Managing Partner. TSA assignments are not available for registered
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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
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Assignment Request Form.
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product, please select one of the following criteria and submit the required documentation:
Criteria Required Documentation
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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
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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
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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
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21134GO 0420 02
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