Fillable Form 1: My beneciary changes STEP Tell us (New York Life)

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Form 1: My beneciary changes STEP Tell us (New York Life)

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21131 11/2020 1
My beneciary
changes
STEP
1
Tell us your policy information. Please print the required information.
Policy number(s)
FIRST M.I. LAST
Policy owner name
Did you know you may be able to update your
beneficiary designation online? Visit newyorklife.com
and click on “My Account” for more information.
If you need assistance completing
this form, please contact us at
(800) CALL-NYL or contact your agent.
If you would like to name a beneficiary for other covered insureds, proceed to Steps 5 and 6.
Q Provide each beneficiary’s social security number, date of birth, address, phone number, and email. This helps us locate beneficiaries and
promptly pay claims.
Q Additional beneficiary information, such as per stirpes, can be provided on the Additional Information Section of this form.
Q We recommend that you also name a secondary beneficiary or indicate how proceeds should be distributed in the event that the primary
beneficiary dies before the insured/annuitant or annuity policy owner.
Q The shared percentages for each class of beneficiary (primary, secondary, and tertiary) must add up to 100%.
▫
P Primary
▫
S
Secondary
▫
T Tertiary
Name
SSN or TIN
▫
Address
Phone number
Email
Name(s) & SSN or TIN
(If naming a minor, please also
complete Step 4)
Class:
Check one
Date of birth or
Date of trust
Relationship to
insured (if Life plan)
or to policy owner
(if Annuity plan)
Share
(% or
Fraction)
QAddress (Check if address is same as policyowner)
QPhone
QEmail
Save time and paper – visit newyorklife.com
and process this transaction securely online
Address
STREET APT. CITY S TAT E ZIP
Preferred phone no. Is this a cell phone? Email
▫
Ye s
▫
No
Trust/Corporate name (if applicable)
Insured/Annuitant’s name ,IGLƪHUHQWWKDQRZQHU Other insured’s name (for Survivorship plans)
FIRST M.I. LAST FIRST M.I. LAST
For Traditional, Roth and SEP IRA Plan types: Please note that available death benefit payout options differ depending on whether your
designated Beneficiary is eligible or non- eligible (determined as of the date of your death) under the Internal Revenue Code (“IRC”). Eligible
designated Beneficiaries are spouses, children under the age of majority, disabled or chronically ill individuals, as determined by the IRC,
(including certain trusts for the disabled or chronically ill), or individuals who are not more than 10 years younger than you. All other individual
Beneficiaries are non-eligible, and all proceeds must be distributed to them by the end of the 10th year following the year of your death (or the
death of both you and the joint annuitant, if applicable).
For Inherited IRA and Inherited Roth IRA Plan types: After your death, your Beneficiaries may be limited to a distribution period that does not
exceed 10 years from the end of the year following the year of death of the original IRA owner or retirement plan participant.
STEP
2 Tell us who you’d like to QDPHDVDEHQHƬFLDU\
)RUDGGLWLRQDOEHQHƬFLDULHVXVHWKHAdditional Information Section in Step 7 of this form.
▫
P Primary
▫
S Secondary
▫
T Tertiary
▫
P Primary
▫
S Secondary
▫
T Tertiary
Name
SSN or TIN
Name
SSN or TIN
▫
Address
Phone number
Email
▫
Address
Phone number
Email
21131 1120 01
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21131 11/2020 2
Q
A custodian is the person named to manage a minor’s property under the Uniform Transfers/Gifts to Minors Act (UTMA/UGMA). Remember, each
minor needs a custodian—the custodian can be the same person for each minor.
Q U
TMA/UGMA state will be the minor’s state of residence listed in Step 2, unless a different state is listed below.
Q
To designate a custodian for additional minor beneficiaries or to designate a successor custodian, provide this information on the “Additional
Information Section” with all details, including the policy number(s) affected as well as your signature and date.
My beneciary changes
Continued from previous page
Additional trustee information can be provided on the Additional Information Section in Step 7 of this form.
Your signature is required on the next page
Q
Section not required for a Testamentary Trust (a trust created within a will). The only required information we need is the name of the individual
ZKRVHZLOOLVEHLQJSODFHGDVDEHQHƬFLDU\IRUH[DPSOHp7HVWDPHQWDU\7UXVWXQGHUWKH/DVW:LOODQG7HVWDPHQWRI-RKQ'RHqLQWKH1DPHRI
trust section below.
Q
A copy of the Title, Signature, and Notary pages of the trust agreement, including the pages showing the trustee and successor trustee
information should be provided. New York Life or its subsidiaries reserves the right to request the entire trust document.
Name of trust Date of trust State where trust established
%HQHƬFLDU\VRIWUXVW Relationship of trustEHQHƬFLDU\VWRLQVXUHGDQQXLWDQW
&OLFNKHUHLIWKLVWUXVWLQIRUPDWLRQLVWRFRYHUIRUDOOWUXVWVWKDWDUHQDPHGDVEHQHƬFLDULHV
Trustee name Address
Phone Email
Relationship of Trustee to insured/annuitant
Trustee name Address
Phone Email
Relationship of Trustee to insured/annuitant
Address
STREET APT. CITY S TAT E ZIP
Custodian daytime Custodian
phone number email
Name of custodian
FIRST M.I. LAST
This custodian is the
same for each minor listed.
▫
Yes
▫
No
Name of minor
FIRST M.I. LAST
UTMA/UGMA state if
GLƪHUHQWWKDQPLQRUoV
state of residence
Name of minor
FIRST M.I. LAST
UTMA/UGMA state if
GLƪHUHQWWKDQPLQRUoV
state of residence
Name of minor
FIRST M.I. LAST
UTMA/UGMA state if
GLƪHUHQWWKDQPLQRUoV
state of residence
STEP 3 ,IDQ\RI\RXUQDPHGEHQHƬFLDULHVDUHDWUXVWSOHDVHFRPSOHWHWKLVVHFWLRQStep 2 must also be completed
.
STEP 4 ,IDQ\RI\RXUQDPHGEHQHƬFLDULHVDUHPLQRUVSOHDVHFRPSOHWHWKLVVHFWLRQ
If Trustee is also Insured, name of Trustee upon death
21131 1120 02
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21131 11/2020 3
My beneciary changes
Continued from previous page
STEP 5A Only complete this step if your policy is a “Family” life insurance plan.
Complete this step to assign a beneficiary to receive proceeds because of the death of the:
1) Second insured covered under a New York Life Family Protection policy OR
2) Spouse covered under the Second Covered Insured (SCI) rider of Family Life Insurance Policy
Q Provide each beneficiary’s social security number, date of birth, address, phone number, and email. This helps us locate beneficiaries and
promptly pay claims.
Q Additional beneficiary information, such as per stirpes, can be provided on the Additional Information Section of this form.
Q We recommend that you also name a secondary beneficiary or indicate how proceeds should be distributed in the event that the primary
beneficiary dies before the insured/annuitant or annuity policy owner.
Q The shared percentages for each class of beneficiary (primary, secondary, and tertiary) must add up to 100%.
▫
P Primary
▫
S Secondary
▫
T Tertiary
Name
SSN or TIN
▫
Address
Phone number
Email
Name(s) & SSN or TIN
(If naming a minor, please also
complete Step 5B)
Class:
Check one
Date of birth or
Date of trust
Relationship to
insured (if Life plan)
or to policy owner
(if Annuity plan)
Share
(% or
Fraction)
QAddress (Check if address is same as policyowner)
QPhone
QEmail
)RUDGGLWLRQDOEHQHƬFLDULHVXVHWKHAdditional Information Section in Step 7 of this form.
▫
P Primary
▫
S Secondary
▫
T Tertiary
▫
P Primary
▫
S
Secondary
▫
T Tertiary
Name
SSN or TIN
Name
SSN or TIN
▫
Address
Phone number
Email
▫
Address
Phone number
Email
Q
A custodian is the person named to manage a minor’s property under the Uniform Transfers/Gifts to Minors Act (UTMA/UGMA). Remember, each
minor needs a custodian—the custodian can be the same person for each minor.
Q U
TMA/UGMA state will be the minor’s state of residence listed in Step 5A, unless a different state is listed below.
Q
To designate a custodian for additional minor beneficiaries or to designate a successor custodian, provide this information on the “Additional
Information Section” with all details, including the policy number(s) affected as well as your signature and date.
STEP 5B ,IDQ\RI\RXUQDPHGEHQHƬFLDULHVIURP6WHS$DUHPLQRUVSOHDVHFRPSOHWHWKLVVHFWLRQ
Address
STREET APT. CITY S TAT E ZIP
Custodian daytime Custodian
phone number email
Name of custodian
FIRST M.I. LAST
This custodian is the
same for each minor listed.
▫
Yes
▫
No
Name of minor
FIRST M.I. LAST
UTMA/UGMA state if
GLƪHUHQWWKDQPLQRUoV
state of residence
Name of minor
FIRST M.I. LAST
UTMA/UGMA state if
GLƪHUHQWWKDQPLQRUoV
state of residence
Name of minor
FIRST M.I. LAST
UTMA/UGMA state if
GLƪHUHQWWKDQPLQRUoV
state of residence
21131 1120 03
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21131 11/2020 4
Complete this step below to assign a beneficiary to receive proceeds payable under life insurance because of the death of:
A
▫
Child covered under a Spouse and Children’s Insurance Rider (SCI) or Children’s Insurance (CI) Rider,
Family Insurance policy, or a New York Life Family Protection policy
OR
B
▫
Name )LUVW0LGGOH/DVW
Covered under the:
▫
Other Covered Insured Rider (O.C.I)
▫
5 Yr. Term Rider
▫
7 Yr. term Rider OR
C
▫
For the primary insured covered under a First-to Die Rider under the:
My beneciary changes
Continued from previous page
STEP 6A Only complete this step if your policy is a “Family” life insurance plan
AND if your policy has a separate rider covering an insured
.
)RUDGGLWLRQDOEHQHƬFLDULHVXVHWKHAdditional Information Section in Step 7 of this form.
▫
P Primary
▫
S Secondary
▫
T Tertiary
Name
SSN or TIN
▫
Address
Phone number
Email
Name(s) & SSN or TIN
(If naming a minor, please also
complete Step 6B)
Class:
Check one
Date of birth or
Date of trust
Relationship to
insured (if Life plan)
or to policy owner
(if Annuity plan)
Share
(% or
Fraction)
QAddress (Check if address is same as policyowner)
QPhone
QEmail
▫
P Primary
▫
S
Secondary
▫
T Tertiary
▫
P Primary
▫
S Secondary
▫
T Tertiary
Name
SSN or TIN
Name
SSN or TIN
▫
Address
Phone number
Email
▫
Address
Phone number
Email
Q
A custodian is the person named to manage a minor’s property under the Uniform Transfers/Gifts to Minors Act (UTMA/UGMA). Remember, each
minor needs a custodian—the custodian can be the same person for each minor.
Q U
TMA/UGMA state will be the minor’s state of residence listed in Step 6A, unless a different state is listed below.
Q
To designate a custodian for additional minor beneficiaries or to designate a successor custodian, provide this information on the “Additional
Information Section” with all details, including the policy number(s) affected as well as your signature and date.
STEP 6B ,IDQ\RI\RXUQDPHGEHQHƬFLDULHVDUHPLQRUVIURP6WHS$SOHDVHFRPSOHWHWKLVVHFWLRQ
Address
STREET APT. CITY S TAT E ZIP
Custodian daytime Custodian
phone number email
Name of custodian
FIRST M.I. LAST
This custodian is the
same for each minor listed.
▫
Yes
▫
No
Name of minor
FIRST M.I. LAST
UTMA/UGMA state if
GLƪHUHQWWKDQPLQRUoV
state of residence
Name of minor
FIRST M.I. LAST
UTMA/UGMA state if
GLƪHUHQWWKDQPLQRUoV
state of residence
▫
Increasing Term Rider (ITR) on a
Survivorship Whole Life (SWL) policy
▫
Level Term First-To-Die Rider (LFD) on
a Survivorship Whole Life (SWL) policy
▫
Level Term First-To-Die Rider (LFD) on a Survivor-
ship Variable Universal Life (SVUL) policy
Q Provide each beneficiary’s social security number, date of birth, address, phone number, and email. This helps us locate beneficiaries and
promptly pay claims.
Q Additional beneficiary information, such as per stirpes, can be provided on the Additional Information Section of this form.
Q We recommend that you also name a secondary beneficiary or indicate how proceeds should be distributed in the event that the primary
beneficiary dies before the insured/annuitant or annuity policy owner.
Q The shared percentages for each class of beneficiary (primary, secondary, and tertiary) must add up to 100%.
21131 1120 04
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21131 11/2020 5
Mail: New York Life, PO Box 130539, Dallas, TX 75313-0539 or Fax: 1-800-278-4117
ONLINE: Save time and postage by uploading this form at newyorklife.com/register. Log in or register to upload in minutes.
STEP 9 Done! Send us your completed form.
Your signature(s) confirm(s) that you have read all the information on this form and that the information you have provided is correct. If the
RZQHULVDFRUSRUDWLRQRUWUXVWSOHDVHSURYLGHVLJQDWXUHVRIWZRFRUSRUDWHRƯFHUVRUUHTXLUHGWUXVWHHV7LWOHVDUHUHTXLUHG
Life insurance policies only: If the owner lives in Massachusetts, a signature is required from a witness over the age of 18 who is not the
insured, policy owner, or a designated beneficiary.
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
X
X
Witness/additional signature Name of Witness (Print) Date
X
My beneciary changes
Continued from previous page
STEP 8 Read and sign.
STEP 7 Additional Information Section
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Then proceed to Step 8.
21131 1120 05
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21131 11/2020 6
Frequently asked questions & things to remember
Continued next page
What information is needed about my beneciary?
Q
Full name
Q
Relationship to the insured/policy owner
Q
Date of birth
*
Q
Social security number
*
Q
Address*
Q
Phone number*
Q
Email*
Q
How proceeds should be divided
Q
1DPHRI870$8*0$FXVWRGLDQLIEHQHƬFLDU\LVDPLQRU
*
3OHDVHSURYLGHHDFKEHQHƬFLDU\oVVRFLDOVHFXULW\QXPEHUGDWHRIELUWKDGGUHVV
SKRQHQXPEHUDQGHPDLO7KLVKHOSVXVORFDWHEHQHƬFLDULHVDQGSURPSWO\SD\
claims.
What are the dierent types of beneciaries?
5HPHPEHU\RXFDQQDPHPRUHWKDQRQHFODVVRIEHQHƬFLDULHV
(such as primary, secondary, or tertiary), and more than one
EHQHƬFLDU\ZLWKLQDFODVV
BENEFICIARY CLASSES:
Q
3ULPDU\RUƬUVWEHQHƬFLDU\ individual(s) or entity(ies) (such
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or annuitant passes away (NOTE - see section below entitled:
“What Special Provisions Apply to Deferred Annuities?”).
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funds will be distributed according to the terms of the
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insured or annuitant, that portion of contract proceeds will be
SDLGWRDQ\UHPDLQLQJSULPDU\EHQHƬFLDULHVLQHTXDOVKDUHV
Q
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are deceased, the class of individual(s) or entity(ies) (such as a
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DQ\EHQHƬFLDU\FODVVIXQGVZLOOEHGLVWULEXWHGDFFRUGLQJWR
the terms of the contract. It’s important to consider naming
DVHFRQGDU\EHQHƬFLDU\EHFDXVHLIWKHSULPDU\EHQHƬFLDU\
passes away before the insured or annuitant and a secondary
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estate of the policy owner. This may require that the estate
be probated.
Q
7HUWLDU\RUWKLUGEHQHƬFLDU\ if all primary and secondary
EHQHƬFLDULHVDUHGHFHDVHGWKHLQGLYLGXDOVRUHQWLW\LHV
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insured or annuitant passes away. If there are no living
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according to the terms of the contract.
PER STIRPES DESIGNATION:
Q
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SDVVHVHTXDOO\WRDQ\OLYLQJFKLOGUHQRIWKDWEHQHƬFLDU\
REVOCABLE VS. IRREVOCABLE BENEFICIARIES:
Q
5HYRFDEOHEHQHƬFLDU\DUHYRFDEOHEHQHƬFLDU\FDQEH
changed by the owner at any time.
Q
,UUHYRFDEOHEHQHƬFLDU\DQLUUHYRFDEOHEHQHƬFLDU\KDVD
YHVWHGLQWHUHVWLQWKHGHDWKEHQHƬWZKLFKFDQoWEHFDQFHOOHG
ZLWKRXWWKHEHQHƬFLDU\oVZULWWHQFRQVHQW
Q
Testamentary Trust: A trust created by an individual’s last
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of the individual who created the will. A will may contain more
than one testamentary trust, and may address all or any
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testamentary trust, policy proceeds cannot be paid to the
trust until the estate is probated, or if the state allows a
VPDOOHVWDWHDƯGDYLWWREHƬOHG
Q
%HQHƬFLDU\IRU9DOXH This designation can be used when
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SURFHHGV$EHQHƬFLDU\IRUYDOXHGHVLJQDWLRQW\SLFDOFRQWDLQV
WKHSKUDVHpDVLWVLQWHUHVWVPD\DSSHDUq$EHQHƬFLDU\IRU
YDOXHFDQoWEHFKDQJHGZLWKRXWWKHEHQHƬFLDU\oVZULWWHQ
consent.
Q
)XQHUDOKRPHDV%HQHƬFLDU\ Before designating a funeral
KRPHDVEHQHƬFLDU\ZHUHFRPPHQG\RXFRQVXOWDOHJDO
professional. Other alternatives may better serve your
intention, such as a collateral assignment in favor of a funeral
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a copy of a Pre-need Arrangement (form provided by funeral
home) is required in certain jurisdictions. If you need
assistance, please contact us at the number listed on the top
of this form, visit newyorklife.com, or contact your agent.
What if my beneciary is a minor?
Minors can’t directly receive payments. Unless you specify a
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Uniform Transfers to Minors Act (UTMA) or Uniform Gifts to
Minors Act (UGMA), we will require a court appointed custodian/
guardian for the estate of the minor to present a claim on behalf
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with obtaining a court appointed custodian/guardian for the mi-
nor child, you may want to consider designating a custodian under
an applicable state’s UTMA/UGMA.
For a trust beneciary, what information is needed?
Q
Name of trust
Q
Date of the trust agreement
Q
Name of trustee(s) and contact information
Q
Tax ID number
How do I specify the amount of proceeds to
leave to each beneciary?
You can specify the amount you want to leave to each
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percentage (%) of proceeds to be payable to each must be
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6SHFLƬFGROODUDPRXQWVZLOOQRWEHDFFHSWHG
21131 1120 06
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21131 11/2020 7
Frequently asked questions & things to remember
Continued from previous page
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IUDFWLRQLVQoWVSHFLƬHGWKHSURFHHGVZLOOEHVSOLWHTXDOO\DPRQJ
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WKHUHDUHQROLYLQJSULPDU\EHQHƬFLDULHVWKHSURFHHGVZLOOEH
SDLGWRWKHQDPHGEHQHƬFLDULHVLQWKHQH[WEHQHƬFLDU\FODVVDQG
so forth. The contract provisions will control the payment of the
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annuitant
What if I get a divorce or annulment?
In most states, if your intent is for your ex-spouse to remain
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GHVLJQDWLRQDIWHU\RXUGLYRUFHLVƬQDOL]HGGHVLJQDWLQJWKH
relationship as ex-spouse. We recommend you speak with a
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divorce decree may require you to maintain your child or former
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What if my contract has multiple owners?
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What special provisions apply to Deferred
Annuities?
If a deferred annuity has not begun paying income payments, the
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this is “Spousal Continuance” described below. If any Owner is
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death of the Annuitant.
Spousal Continuance: If the annuity owner’s spouse is named
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be continued with the surviving spouse as the new owner, if so
provided in the contract. If the deceased annuity owner was also
the sole annuitant, the surviving spouse will also become the
new annuitant. If the surviving spouse chooses to continue the
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ownership, while both owners are living, if the sole primary
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of the surviving spouse to continue the contract will not be in
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What if I have an irrevocable beneciary?
For annuity contracts:,UUHYRFDEOHEHQHƬFLDU\GHVLJQDWLRQV
can only be changed with the written consent of the irrevoca-
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contract, or as required by law, the policy owner’s rights are not
otherwise restricted.
For life contracts: Owner’s rights are restricted. The irrevocable
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SURFHVVLQJDQ\FRQWUDFWXDOFKDQJHV7KHVHLQFOXGHEHQHƬFLDU\
changes, loans and withdrawals, the right to exercise the
Non-Forfeiture Option, and the right to assign or surrender
the contract.
Did you get the signatures you need?
Q
Policy owner
Q
-RLQWRZQHULIDQ\
Q
,UUHYRFDEOHEHQHƬFLDU\LIDQ\
Q
Witness (Massachusetts residents life insurance policies only)
Power of Attorney
If a Power of Attorney (POA) is signing the form, the POA
document should be current and in certain states the right to
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21131 1120 07
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Form 1: My beneciary changes STEP Tell us (New York Life)

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Completed 9 April 2022

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