Oceanview Life and Annuity Company
www.oceanviewlife.com
1-888-295-3815
Overnight Mail:
1851 SE Miehe Dr.
Grimes, IA 50111
Administrative Office:
PO Box 830
Grimes, IA 50111
NEW BUSINESS APPLICATION CHECKLIST: UTAH
Individual Single Premium Deferred Annuity Application (Form Code: ICC19 OLA SPDA-APP)
NOTE: Required
Harbourview Multi-Year Guaranteed Annuity Product Disclosure (Form Code: OVLAC-MYGA-DISC)
NOTE: Required
Fixed Annuity Suitability Questionnaire (Form Code: OVLAC-SUITABILITY)
NOTE: Required
Notice of Replacement of Life Insurance or Annuities (Form Code: OVLAC-REP-GENERIC)
NOTE: Only if Applicable
Request for Rollover, Transfer or Exchange (Form Code: OVLAC-TRANSFER)
NOTE: Only if Applicable
o If rollover is 403b (Form Code: OVLAC-APP-403B)
Trust Verification Form for Annuities (Form Code: OVLAC-APP-TRUST)
NOTE: Only if Applicable
o If additional space is required to list Trustees (Form Code: OVLAC-TRUSTEE_ADDTL)
Beneficiary Designations (Form Code: OVLAC-BENE_ADDTL)
NOTE: If additional space is required for more than 2 Beneficiaries
www.oceanviewlife.com
1-833-656-7455
Overnight Mail:
1851 SE Miehe Dr.
Grimes, IA 50111
Administrative Office:
PO Box 830
Grimes, IA 50111
1-888-295-3815
NEW BUSINESS APPLICATIONS:
Paper Submissions-
1. OvernightMailAddress
Attn:Oceanview
1851SE MieheDr
Grimes,IA50111
2. RegularMailAddress
Attn:Oceanview
POBox830
Grimes,IA50111
Oceanview Life and Annuity Company
FOR QUESTIONS IN REGARDS TO SALES OR PRODUCT:
Call your Marketing Group or Oceanview Sales & Marketing Team at 1-833-656-7455
FOR QUESTIONS IN REGARDS TO AGENT APPOINTMENT OR POLICY INFORMATION:
Call the Oceanview Administrative Office at 1-888-295-3815
Fax Submissions- 678-394-5901
1
OCEANVIEW LIFE AND ANNUITY COMPANY
Regular Mail: PO Box 830, Grimes, IA 50111 P: 888-295-3815
Overnight Mail: Attn: Oceanview 1851 SE Miehe Dr. Grimes, IA 50111
FAX: 678-394-5901
www.oceanviewlife.com
INDIVIDUAL SINGLE PREMIUM DEFERRED ANNUITY APPLICATION
TYPE OF APPLICATION: Individual Joint Custodial (UGMA/UTMA)
Non-Natural Person (Trust/Corp/Non-Corp Entity) Qualified
Is the Annuitant the same as the Owner? Yes No
1. OWNER (if Natural Person)
First MI
Last
Residence Address (cannot be a P.O. Box) City
State Zip
Mailing Address (If different than residence address) City
State Zip
Phone Number
( )
Date of Birth
(MM/DD/YYYY)
Male
Female
Marital Status
Single
Married
Social Security #
Is the Owner a US Citizen? Yes No
If not a US Citizen, provide the following
information
Country of Citizenship
Type of Visa Exp. Date
If Custodian, please provide the following
information for Individual or Entity
First MI
Last (or name of Entity)
2. JOINT OWNER INFORMATION
(Must be legal spouse)
First MI
Last
Phone number
( )
Email address
Date of Birth (MM/DD/YYYY)
Social Security #
Residence Address (If different than Owner’s residence address) City
State Zip
Mailing Address (If different than Owner’s mailing address) City
State Zip
Is the Joint Owner a US Citizen? Yes
No
If not a US Citizen, provide the following
information
ICC19 OLA SPDA-APP
Rev. 06/20
2
3. TRUST/CORPORATE/NON-CORPORATE ENTITY (if Trust, complete Trust Form)
Trust/Corp Name Contact Name
Tax ID State
4. ANNUITANT (If different than the Owner)
First MI Last
Residence Address (cannot be a P.O. Box) City State Zip
Mailing Address (If different than residence address) City State Zip
Phone Number
( )
Email Address
Date of Birth
(MM/DD/YYYY)
Male
Female
Marital Status
Single
Married
Social Security #
Is the Annuitant a US Citizen? Yes No
If not a US Citizen, provide the following
information
Country of Citizenship Type of Visa Exp. Date
If Custodian, please provide the following
information for Individual or Entity
First MI Last (or name of Entity)
5. JOINT ANNUITANT (If different than the Owner)
First MI Last
Residence Address (cannot be a P.O. Box) City State Zip
Mailing Address (If different than residence address) City State Zip
Phone Number
( )
Email Address
Date of Birth
(MM/DD/YYYY)
Male
Female
Marital Status
Single
Married
Social Security #
Is the Annuitant a US Citizen?
Yes
No
If not a US Citizen, provide the following
information
Country of Citizenship Type of Visa Exp. Date
If Custodian, please provide the following
information for Individual or Entity
First MI Last (or name of Entity)
ICC19 OLA SPDA-APP
Rev. 06/20
3
6. BENEFICIARY DESIGNATION
(Include additional beneficiaries on an additional page attached to
this application.) Percentages must be in whole numbers. Both Primary and Contingent Beneficiary
percentages must each add up to 100%.
Primary
First MI Last Name
Address, City, State, Zip
Relationship
SSN
%
Contingent
First MI Last Name
Address, City, State, Zip
Relationship
SSN
%
Contingent
First MI Last Name
Address, City, State, Zip
Relationship
SSN
%
Contingent
First MI Last Name
Address, City, State, Zip
Relationship
SSN
%
7. POLICY & PREMIUM DETAILS
Funds Are: Non-Qualified Qualified
Source of funds:
Check Amount $_________________
1035 Exchange A
mount $_________________ Company _____________________________
Rollover/
Transfer Amount $_________________ Company ____________________________
Amount $________
_________ Company ____________________________
Tax-Qualified Plans: Traditional IRA Roth IRA Roth Conversion
Inherited IRA
Simplified SEP Other ______________________________
Surrender Charge Period: 3 5 7 10 Years
Rider:
Market Value Adjustment Rider
8. OTHER COVERAGE & ARRANGEMENTS
Does the Proposed Owner have any existing life insurance or annuity contracts? Yes No
Is this policy being purchased to replace any existing life insurance or annuity contract? Yes No
If Yes, Please complete the following:
COMPANY NAME
POLICY #
SURRENDER VALUE
STREET ADDRESS
CITY
STATE
ZIP
ICC19 OLA SPDA-APP
Rev. 06/20
4
9. STATEMENTS AND AUTHORIZATIONS
PROPOSED OWNER’S STATEMENT
I have read and understand this Application. I am not currently taking and I am not under the influence of any
medications or drugs that would affect my ability to fully understand and to fully and accurately complete this
Application. The representations in this Application are true. I agree the annuity contract shall not be in effect
until it has been issued by Oceanview Life and Annuity Company (“the Company”) and the single premium is
paid. I understand that the Producer has no authority to approve this Application, change the annuity contract,
or waive any contract provisions. I understand that the annuity contract will not be effective until the date
signed in the contract and all eligibility requirements are met.
FRAUD NOTICE/WARNING:
Any person who knowingly submits a false statement in an Application for
insurance may be guilty of a criminal offense and subject to penalties under state law. I have read, understand,
and acknowledge the Fraud Notice.
Owner’s Signature Date City, state where signed
Joint Owner’s Signature Date City, state where signed
PRODUCER’S STATEMENT
I further certify that any information recorded by me on this Application is true and accurate to the best of my
knowledge and that the Owner seemed to me to be lucid and to fully understand all of the questions on this
Application.
Producer’s Signature Producer’s Printed Name Producer’s Number Date
PLEASE COMPLETE IF THERE IS A CO-PRODUCER:
Co-Producer’s Signature Co-Producer’s Printed Name Co-Producer’s Number Split%
ICC19 OLA SPDA-APP
Rev. 06/20
Oceanview Life and Annuity Company
Description
Harbourview MYGA is a Single Premium Deferred Annuity
(Policy Form: ICC19 OLA SPDA-*) designed to accumulate money for
retirement. It is suitable for use as an IRA or other qualified account, as
well as an attractive alternative to CDs and other taxable vehicles. You
can start your Harbourview MYGA with a minimum
premium of $10,000
.
How Interest is Credited
Interest is credited at the initial interest rate guaranteed for the first
Guarantee Period. At the end of the Guarantee Period, and each
subsequent Guarantee Period thereafter, a new rate will be declared. Your
annuity will earn a declared interest rate, which may go up or down, but
can never be less than the contract’s minimum guaranteed rate at the time
of your purchase. Your interest is credited and compounded daily to yield
our declared annual rate. There are no front-end sales charges or annual
administrative fees. 100% of your money works for you!
Until the policy is issued, rates are subject to change without notice
Market Value Adjustment (MVA)
The MVA may be applied during the surrender charge period of your
annuity Contract. The surrender charge period will vary by product.
Please see your annuity Contract or product brochure for details. The
MVA only applies during the surrender charge period should you elect to
surrender your annuity or take a withdrawal that exceeds your penalty-
free withdrawal amount. The Market Value Adjustment does not apply
upon death of the owner(s) or the annuitant when the owner is a non-
natural person, upon annuitization or after the surrender charge period.
The MVA affects the surrender value of your annuity which is defined in
your annuity contract. The Market Value Adjustment formula will be
applied at the time your annuity Contract is surrendered or if more than
your penalty-free available is withdrawn during the surrender charge
period as stated in your Contract. The impact of the MVA is similar to
OVLAC‐MYGA‐DISC
Rev. 06/20
how bond values are impacted by interest rates. The surrender value of
your annuity will generally decrease if interest rates for your annuity
product increase which creates a negative adjustment to your surrender
value. Alternatively, when interest rates for your annuity product have
decreased since your Contract was issued, the surrender value generally
increases due to the Market Value Adjustment.
Policy Values
Your Contract Value is 100% of all premiums and earned interest.
The Cash Surrender Value is the Contract Value less any cash
withdrawals and applicable surrender charges and Market
Value
Adjustment (MVA).
Surrender charges and MVA are waived in the
event of the Owner’s death. Prior cash withdrawals are deducted from
the Contract Value, Cash Surrender Value and Death Benefit.
Liquidity
You may have access to your annuity at any time permitted by law.
After the first contract year, you may withdraw up to 10% of the
Contract Value as of the prior Contract Anniversary (Free
Withdrawal Amount)*. No surrender charges or MVA fees apply.
You may take as many partial withdrawals as you want up to your
Free Withdrawal Amount without incurring any Surrender Charges or
MVA adjustments. Withdrawals in excess of the Free Withdrawal
Amount are subject to a MVA and the following charges:
Withdrawals may also be subject to a 10% IRS penalty on
amounts withdrawn before the owner reaches age 59½.
Payout Options
There is a wide range of annuity settlement options from which
you may choose, including: life only, life with 10 yearscertain,
and fixed period payments. A customized payout option may be
tailored to meet your specific needs.
If you elect to annuitize non-qualified money, generally only a
portion of each payment is taxable because a part of each
payment is a return of your premium.
Harbourview MYGA Advantage
Tax Deferred Your annuity can grow faster than alternative
vehicles because:
You earn interest on your principal.
You earn interest on your interest.
You earn interest on the money you would otherwise pay in
taxes.
You don’t owe tax on interest until you take it out.
Harbourview Multi-Year
Guaranteed Annuity
Product Disclosure
Other Important Features
Your money is never directly subject to stock market risk.
You pay no front-end sales charges or annual maintenance
fees. 100% of your money is always earning interest for you
(state
premium taxes may be deducted, if applicable).
X
Owner’s Signature
X
Joint Owner’s Signature (if any)
Owner’s Name
Joint Owner’s Name (if any)
Producer’s Signature
Date
Producer’s Name (please print)
Harbourview MYGA is subject to state approval. Product features,
options and availability may vary by state.
Lifetime payments and guarantees are based on the claims paying ability
of the company.
This is a brief description of the Harbourview MYGA and is meant for
informational purposes only. It is not individualized to address any
specific investment objective. It is not intended as investment or financial
advice. Please refer to your Contract for any other specific information
including limitations, exclusions and charges.
Annuities held within qualified plans do not provide any additional tax
benefit. With certain exceptions, surrender charges apply to withdrawals
taken during the initial Guarantee Period and a market value adjustment,
which may increase or decrease the amount received upon withdrawal,
may also apply at any time.
We deduct Premium taxes, if applicable, imposed on us by a
federal, state, local, or other government agency. Some
states collect these taxes on Premium Payments; others
collect at annuitization. Since we pay Premium Taxes when
they are required by applicable law, we may deduct them
from Your Contract when we pay the taxes, when you
withdraw your contract value, when you start to receive
income payments or when it pays a death benefit to your
beneficiary. The Premium tax rate varies by state or
municipality and currently ranges from 0 - 3.5%.
All or a portion of amounts withdrawn are subject to ordinary income tax,
and if taken prior to age 59 ½, a 10% IRS penalty may also apply. We
do not provide tax, financial or investment advice, or act as a fiduciary in
the sale or service of the product. Consult a tax advisor or financial
representative about your specific circumstances.
*Surrender charges may also be waived for some Required Minimum
Withdrawals (RMD). See your contract for additional information.
OVLAC‐MYGA‐DISC
Rev. 06/20
OVLAC-SUITABILITY
Rev. 06/20
1 | P a g e
FIXED ANNUITY SUITABILITY QUESTIONNAIRE
Name of Owner(s)
Owner’s Current Age
Joint Owner’s (if any) Current Age
Name of Product Purchased
Approximate Premium
1. Annual Income: Gross Household Income of contract owner(s):
$0 $25,000 $25,001 $50,000 $50,001 $75,000 $75,001 $100,000
$100,001 $250,000 $250,001 - $500,000 Greater than $500,000
2. Financial Experience (check one):
Limited: The proposed contract owner has made limited financial decisions prior to this
application with little experience with financial markets and/or credit transactions.
Moderate: The proposed owner has made previous financial decisions such as a home
or automobile loan; credit card use; purchased other annuity contracts or life insurance
policies; made a financed purchase; invested in a retirement plan such as a 401(k) or
403(b); purchased or held mutual funds; etc.
Advanced: The proposed owner has made previous financial decisions including stock or
bond purchases and or trades; proposed owner has participated in private placement
offerings; proposed ownerhas participated in advanced financial transactions, etc.
3. Risk Tolerance for this contract’s funds (check one):
Conservative: Owner has little tolerance for volatility and/or principal loss.
Moderate: Owner has some tolerance for short-term volatility and/or principal loss.
Aggressive: Owner has tolerance for and expectations of volatility and principal loss
and/or gain.
4. Federal Income Tax Bracket:
0% 10 or 12% 22 or 24% 32, 35 or 37%
5. Financial Objectives for this Contract (check all that apply):
Income for Today Income for Life Guaranteed Interest Rate Principal Protection
Tax Benefits Pass Along to Benefits Accumulation Other:
OVLAC-SUITABILITY
Rev. 06/20
2 | P a g e
6. Funding of this annuity (check all that apply):
Earnings/Wages Cash Value from Life Insurance/Annuity Savings/Checking
Gift Mutual Fund/Stock/Bond Redemption Death Benefit Proceeds CD
Retirement Fund/Rollover Reverse Mortgage/Home Equity Loan
7. Financial Time Horizon:
Less than 1 year 1-3 Years 4-6 Years 7-10 Years More than 10 Years
8. Liquid Net Worth:
Under $50,000 $50,001-$100,000 $100,001-$250,000 More than $250,000
9. Percentage of Liquid Net Worth Represented by this Contract:
Less than 10% 10% - 25% 25%-50% More than 50%
10. Other than the premium in this annuity, will the annuitant have sufficient funds or other assets
available to access, without penalty, for living expenses and in case of emergencies?
Yes No
11. Are any of the following changes anticipated during the surrender charge period of the proposed
annuity? If yes, please explain including the expected changes and amount.
a. Significant increases/decreases in living expenses? Yes No
If Yes, explain:
b. Significant increases/decreases in income? Yes No
If Yes, explain:
c. Significant increases/decreases in net worth or liquid assets? Yes No
If Yes, explain:
12. Has the proposed owner replaced or exchanged another life insurance or annuity contract within
the past 3 years? Yes No
13. Does t
he proposed owner have a reverse mortgage? Yes No
The basis for recommending this annuity is (section must be completed, include additional
documentation if necessary):
OVLAC-SUITABILITY
Rev. 06/20
3 | P a g e
OWNER’S CERTIFICATION: STATEMENT OF UNDERSTANDING
I attest to this Statement of Understanding. I have completed or reviewed this form and to the best
of my knowledge the information provided on the Fixed Annuity Suitability Questionnaire is
accurate. I understand the insurer may contact me to verify information provided or to seek further
information. My financial professional has reviewed the features and benefits of this purchase as
well as any applicable fees and charges associated with this purchase. I acknowledge that my
financial professional does not provide legal or tax advice. I believe that the purchase of this annuity
contract is suitable for my financial needs and objectives.
Owner(s) Signatures
Date
Owner(s) Names
Owner(s) Contact Information (at least one is required):
Phone Number
Email Address
Cell Number
PRODUCER’S CERTIFICATION:
I have made a reasonable effort to obtain information from the proposed owner(s) concerning
his/her financial status, objectives and other pertinent information. I have delivered information to the
applicant concerning the costs and benefits of the annuity. Based on the facts disclosed by the
proposed owner(s), and all information known to me at this time, I have reasonable grounds to
believe that the recommendation to purchase or exchange this annuity contract is suitable and that
certain features of the annuity will provide benefit. Furthermore, I agree to maintain and make available
upon request to the insurer or the insurance commissioner, records of the information collected,
including any additional needs analysis forms, and other information used as the basis for this annuity
contract recommendation for the number of years required by state laws or regulations. I
understand the insurer may contact the proposed owner for additional information.
Producer Signature
Date
Producer Name
Producer Contact Information (at least one is required):
Phone Number
Email Address
Cell Number
OVLAC-REP-GENERIC
Rev. 06/20
1 of 2
Oceanview Life and Annuity Company
P
O Box 830 Grimes, IA 50111-0830
Tel 888.295.3815 www.oceanviewlife.com
Notice of Replacement of Life Insurance or Annuities
You are contemplating the purchase of a life insurance policy or annuity contract. In some cases this purchase may involve
discontinuing or changing an existing policy or contract. If so, a replacement is occurring. Financed purchases are also
considered replacements.
A replacement occurs when a new policy or contract is purchased and, in connection with the sale, you discontinue making
premium payments on the existing policy or contract, or an existing policy or contract is surrendered, forfeited, assigned to
the replacing insurer, or otherwise terminated or used in a fi nancial purchase.
A fi nanced purchase occurs when the purchase of a new life insurance policy involves the use of funds obtained by the
withdrawal or surrender of or by borrowing some or all of the policy values, including accumulated dividends, of an existing
policy or contract to pay all or part of any premium or payment due on the new policy. A fi nanced purchase is a replacement.
You should carefully consider whether a replacement is in your best interests. You will pay acquisition costs and there may be
surrender costs deducted from your policy or contract. You may be able to make changes to your existing policy or contract
to meet your insurance needs at less cost. A fi nanced purchase will reduce the value of your existing policy and may reduce
the amount paid upon the death of the insured individual.
We want you to understand the effects of replacements before you make your purchase decision and ask that you answer the
following questions and consider the questions on page 2 of this form.
A. Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer or
otherwise terminating your existing policy or contract? G Yes G No
B. Are you considering using funds from your existing policies or contracts to pay premiums due on the new policy or
contract? G Yes G No
C. If you answered “Yes” to either of the above questions, list each existing policy or contract you are contemplating
replacing (include the name of the insurer, the insured or annuitant, and the policy or contract number, if
available) and whether each policy or contract will be replaced or used as a source of fi nancing:
INSURER NAME CONTRACT/POLICY NUMBER NAME OF INSURED OR ANNUITANT REPLACED ( R ) OR FINANCING ( F )
_______________________ __________________ ___________________________ ____________________
_______________________ __________________ ___________________________ ____________________
_______________________ __________________ ___________________________ ____________________
Make sure you know the facts. Contact your existing company or its agent for information about the old policy or contract.
If you request, an in force illustration, policy summary or available disclosure documents must be sent to you by the existing
insurer. Ask for and retain all sales material used by the agent in the sales presentation. Be sure that you are making an
informed decision.
D. The existing policy or contract is being replaced because ___________________________________________________.
2 Acknowledgement
OWNER NAME(S)
I(We) certify that the responses herein are, to the best of my(our) knowledge, accurate.
_______________________________________________________________________________________________________________________________ _______________________________
OWNER SIGNATURE DATE
_______________________________________________________________________________________________________________________________ _______________________________
OWNER SIGNATURE DATE
I(We) do not want this notice read aloud to me(us): _____________ (Applicants must initial only if they do not want the notice read aloud.)
REASON FOR REPLACEMENT
INITIALS
1 Important Notice: Replacement of Life Insurance or Annuities
(This notice must be signed by the applicant(s) and broker, with the original sent to Oceanview Life and Annuity Company and a copy left with the applicant(s).) This
form is suitable for the following states: AK, AL, AR, AZ, CO, CT, IA, KY, LA, MD, ME, MO, MS, MT, NE, NH, NJ, NM, OH, OR, RI, SC, TX, UT, VA, VT, WI and WV
2 of 2
3 Important Replacement Issues
A replacement may not be in your best interest, or your decision could be a good one. You should make a careful comparison
of the costs and benefi ts of your existing policy or contract and the proposed policy or contract. One way to do this is to ask
the company or agent that sold you your existing policy or contract to provide you with information concerning your existing
policy or contract. This may include an illustration of how your existing policy or contract is working now and how it would
perform in the future based on certain assumptions. Illustrations should not, however, be used as a sole basis to compare
policies or contracts. You should discuss the following with your agent to determine whether replacement or fi nancing your
purchase makes sense.
Policy Value
Acquisition costs for the old policy may have been paid, and you may incur costs for the new one.
What surrender charges do the policies have?
What expense and sales charges will you pay on the new policy?
Does the new policy provide more insurance coverage?
Insurability
If your health has changed since you bought your old policy, the new one could cost you more, or you
could be turned down.
You may need a medical exam for a new policy.
Claims on most new policies for up to the fi rst two years can be denied based on inaccurate statements.
Suicide limitations may begin anew on the new coverage.
If you are keeping the old policy as well as the new policy
How are premiums for both policies being paid?
How will the premiums on your existing policy be affected?
Will a loan be deducted from death benefi ts?
What values from the old policy are being used to pay premiums?
If you are surrendering an annuity or interest sensitive life product
Will you pay surrender charges on your old contract?
What are the interest rate guarantees for the new contract?
Have you compared the contract charges or other policy expenses?
Other issues to consider for all transactions
What are the tax consequences of buying the new policy?
Is this a tax-free exchange? (See your tax advisor.)
Is there a benefi t from favorable “grandfathered” treatment of the old policy under the federal tax code?
Will the existing insurer be willing to modify the old policy?
How does the quality and fi nancial stability of the new company compare with your existing company?
4 Producer
NAME
Copies of any and all “individualized” sales materials, including illustrations related to the speci c annuity contract, used in
the presentation must be provided to Oceanview Life and Annuity Company.
I certify that: (a) the responses herein are, to the best of my knowledge, accurate; (b) I have left with the applicant(s)copies
of all sales materials used in my presentation; and (c) the following preprinted or electronically presented carrier-approved
materials were used in my presentation (please list by title and form number):
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
_______________________________
_______________________________________________________________________________________________________________________________
PROD
U
CER SIG
NATURE
DATE
OVLAC-REP-GENERIC
Rev. 06/20
OVLAC-TRANSFER
Rev. 6/20
1 of 2
Oceanview Life and Annuity Company
PO Box 830 Grimes, IA 50111
888.295.3815 Tel
www.oceanviewlife.com
1
Transferring Institution
Request for Rollover, Transfer or Exchange
COMPANY OR CUSTODIAN PHONE
STREET ADDRESS (NOT A POST OFFICE BOX) CITY STATE ZIP CODE
2
Existing Policy or Account
OWNER(S) OWNER SSNs (or TINs)
ADDRESS CITY STATE ZIP CODE
ANNUITANT(S), INSURED(S) OR PARTICIPANT ANNUITANT, INSURED(S) OR PARTICIPANT SSNs (or TINs)
BENEFICIARY (IF PARTICIPANT IS DECEASED) BENEFICIARY SSN (or TIN)
INVESTMENT VEHICLE
CD Life Insurance Annuity Custodial Account Other
ACCOUNT OR CONTRACT NUMBER(S)
3
Transaction Type (Complete section A or B.)
A
Qualified Funds
(For rollover, transfer or exchange into a 403(b) Tax-Sheltered Annuity, use form
Funds From Funds To
Traditional IRA
Inherited IRA
Roth IRA
SEP IRA
403(b) TSA
Qualified Pension
or Profit Sharing Plan
Initiated by Participant
Traditional IRA
Roth IRA
SEP IRA
Qualified Pension
or Profit Sharing Plan
Initiated by Beneficiary
Inherited IRA (Attach form OVLAC
APP-IRA)
Oceanview Life and Annuity Company’s Traditional IRA, Roth IRA, SEP and 403(b) contracts meet the
requirements of
Internal Revenue Code § 408(b), 408A, 408(k) and 403(b)(1) respectively.
B
Non-Qualified Funds
Transaction Type:
Direct Transfer
1035 Exchange
Additional Funds Forthcoming After This Transfer:
No Yes: $
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this policy, that no proceeding in bankruptcy is pending or has been filed affecting the policy, and that any collateral
assignment of the policy has been properly released by the collateral assignee prior to the execution of this Absolute
Assignment contract’s benefits and provisions within a reasonable time.
OVLAC-APP-403B
FAX
OVLAC-TRANSFER
Rev. 6/20
2 of 2
4
Lost Policy Statement (Applicable only to a full surrender to effect the rollover, transfer or exchange.)
5
Participant/Beneficiary Declaration (Complete only for rollover of 403(b) Tax-Sheltered Annuity funds.)
6
Authorization
7
Request for Funds Transfer (To be completed only by an authorized Oceanview Life and Annuity Company home-office employee.)
The undersigned certifies that:
The policy or contract is attached.
The policy or contract is lost or has been destroyed. To the best of my knowledge it is not in anyone’s possession.
GUARANTEE SIGNATURE (IF APPLICABLE)
OWNER SIGNATURE
OWNER OR BENEFICIARY SIGNATURE
f f
% or $ as cash from the policy or account to Oceanview Life and Annuity Company:
Transfer Immediately (default action if no selection is made)
Transfer on Maturity or Anniversary Date
Transfer on
DATE
f ff
AUTHORIZED OCEANVIEW LIFE AND ANNUITY COMPANY HOME OFFICE EMPLOYEE SIGNATURE
new or existing policy with Oceanview Life and Annuity Company.
Oceanview Life and Annuity Company
OWNER(S), ANNUITANT(S) OR BENEFICIARY NAME
P.O. Box 830
Grimes, IA 50111-0830
.
CONTRACT NUMBER
The requested action is a 1035 Exchange, therefore please:
AUTHORIZED OCEANVIEW LIFE AND ANNUITY COMPANY HOME OFFICE EMPLOYEE PRINTED NAME
AUTHORIZED OCEANVIEW LIFE AND ANNUITY COMPANY HOME OFFICE EMPLOYEE TITLE
OVLAC-APP-IRA
Rev. 06/20
1 of 1
Request for Inherited Individual Retirement Annuity
Attach 1) IRS forms W-9 and W-4P, 2) a copy of the decedent’s death
certificate and 3) a copy of the most recent account
statement.
1 Applicant
NAME
2 Inherited Account
ACCOUNT TYPE
Traditional IRA Roth IRA _______________ 403(b) TSA Other Qualified Plan
DECEDENT NAME SSN (or TIN) ACCOUNT NUMBER
RELATIONSHIP TO APPLICANT BIRTH DATE DEATH DATE
ADDRESS AT TIME OF DEATH CITY STATE ZIP CODE
3 IRS Required Minimum Distribution (For payments via direct deposit, attach form 114 2 6.)
REQUESTED PAYMENT START DATE PAYMENT MODE
Monthly Quarterly Semiannually Annually
(Complete only if the applicant is the beneficiary of assets from an Inherited IRA account.)
Has the applicant started to receive IRS Required Minimum Distributions?
No Yes : Beginning Year _____________
Age Used for Calculation _____________
Was the calculation based on multiple beneficiaries?
No Yes : Oldest Beneficiary’s Date of Birth: _________________________
4 Previous Account Holder (Complete only if the applicant is the beneficiary of assets from a previously inherited IRA.)
NAME BIRTH DATE DEATH DATE
5 Trust Beneficiary (Complete only if applicable: A trust beneficiary may purchase an Inherited IRA only if it is qualified to do so. For a trust to
qualify for an Inherited IRA it must be 1) valid under state law, 2) irrevocable and 3) name identifiable beneficiaries, who are all individuals.)
I am transferring or rolling over inherited assets from an IRA or employer-sponsored retirement plan account to an
Inherited IRA for the benefit of a qualifying trust. By checking this box, I certify that the trust is a qualifying, non-
spouse beneficiary for the purposes of Section 402(c) of the Internal Revenue Code and is therefore eligible to directly
transfer or roll over IRA or employer-sponsored plan assets to an Inherited IRA. I have attached a copy of the trust
agreement (or a trustee-certification) along with a complete list of all trust beneciaries (including contingent and
remainder beneficiaries) and a description of conditions applicable to their entitlement.
6 Authorization
I have completed the applicable sections of this form and represent that all information provided is true and accurate.
I understand that additional deposits will not be accepted for Inherited IRA contracts.
_____________________________________________________________________________________________________________________________ _______________________________
DATE OF PURCHASE
AGE
YEAR
DATE OF BIRTH
APPLICANT SIGNATURE DATE
Oceanview Life and Annuity Company
P
O Box 830 Grimes, IA 50111-0830
Tel 888.295.3815 www.oceanviewlife.com
OVLAC-APP-TRUST
Rev.06/20
Page 1 of 2
Trust
Verification
Form for Annuities
1. Contract Information
Contract Number
Name of Annuitant (If different from Contract Owner)
Social Security or Tax I.D. Number
Name of Contract Owner
Social Security or Tax I.D. Number
Street Address, City, State, Zip
Name of Contract Owner (If applicable)
Social Security or Tax I.D. Number
2. Full Name of Trust
Please be sure to accurately state the Trust’s full name
3. Type of Trust
Irrevocable Revocable
4. Date of Trust: 4.a Statute That Governs the Trust:
5. Trust Tax Identification Number (Please check one):
The Trust does not have a separate taxpayer identification number. Thus, the personal taxpayer identification number of the
FIRST Settlor/Grantor listed below should be used; or
The Trust tax identification number is:
6. Names of Settlors/Grantors of Trust
1.
(SSN )
2.
(SSN)
(Please attach additional pages if insufficient space has been provided.)
7. Names of ALL current Trustees:
1.
2.
3.
(Please attach additional pages if insufficient space has been provided.)
8. Names of ALL Successor Trustees (if applicable):
1.
2.
3.
(Please attach additional pages if insufficient space has been provided.)
Oceanview Life and Annuity Company
PO Box 830 Grimes, IA 50111-0830
Tel 888.295.3815 www.
oceanviewlife.com
Page 2 of 2
Oceanview Life and Annuity Company
9. Instructions for Trustee Signature/Authentication
The Trust Agreement requires that; (Please mark the appropriate box)
Any of the Trustees, acting alone
All of the Trustees acting together
Other (explain)
Must sign or otherwise authenticate forms and/or requests on behalf of the Trust in connection with our products.
10. Neither the Insurance Agent nor any person affiliated with the insurance agent is a beneficiary of the Trust
Agree
Disagree
If you marked Disagree, please attach an explanation of why they are named a
beneficiary of the Trust
Note: Under the laws of most states, an agent is restricted in, or prohibited from, having a beneficial interest in a
contract/policy sold by that agent, unless that agent is a family member, or has a recognized insurable
interest.
11. The Trust is validly executed and in full force and effect?
Yes No Note: Trust must be formed and domiciled in the United States or one of its
Territories at all times.
12. Certifications by Trustee(s)
The Trustee(s) states
and agrees that:
The Trust, if named owner, is authorized under the terms of the Trust to purchase and/or hold insurance on
the life of any insured/annuitant. If named beneficiary, the Trust is authorized to receive proceeds as
provided under the terms of the insurance policy and/or annuity contract. I/we have also determined the
insurance product is appropriate for the Trust’s purpose and the terms of the insurance product conforms
to the income distribution requirements, if any, of the Trust.
I/We certify that Oceanview Life and Annuity Company (the “Company”) may rely solely on this
Verification and the information provided for policy/contract administration purposes and the Company
has no obligation to investigate the terms of the Trust or the authority of the Trustee(s). The
Company expressly denies responsibility regarding the use and applications of any payments made to the
Trust by the Trustee(s) and the Trustee(s) will hold the Company harmless from any action the Company
takes at the direction of the Trustee(s).
The Trustee(s) declares that each and every Trustee and successor Trustee are bound by this certification. It is
further understood that the Company may rely upon the direction of the named Trustee(s) until the company receives
written notification at its Home Office of a change of Trustee. Furthermore, the Trustee(s) agrees to notify the
Company of any changes to the Trust itself that will alter the information provided in this Trust Verification.
The signature(s) below certify the previous information provided and agreed to on this Verification is true
and accurate: Notes: The number of Trustees indicated in section 8 must sign below
If additional signature blocks are required, please photocopy this form and attach accordingly
X X
Signature of Trustee Date Signature of Trustee Date
OVLAC-APP-TRUST
Rev.06/20
click to sign
signature
click to edit
click to sign
signature
click to edit
Beneficiary Designations
Beneficiary Type Beneficiary Name Relationship % SSN Date of Birth Gender
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
OVLAC-BENE_ADDTL
REV 01/20
click to sign
signature
click to edit
Trustee Designations
Trustee Name
Trustee Phone
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Trustee Email
OVLAC-TRUSTEE_ADDTL
REV 01/20
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