Fillable Owner Designation Form Instructions

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Owner Designation Form Instructions

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Owner Designation Form
Instructions
Insured(s)
Daytime Telephone Number
Policy Number(s)
• For each new owner designation please complete all required information; review for accuracy, sign and return the form
to the address or fax number listed below. For more detailed instructions, please see page 4 of this form.
• Please note the Application revokes all previous owner designations. Therefore, even if a primary owner or a contingent
owner is to remain the same, such owner must be restated on this form.
Insured Information
Primary Owner Designation
Please change the Owner of the policy listed above to (Select from options A, B, C or D). If no contingent owner is designated,
the estate of the owner or the estate of the last joint owner to die will succeed to all the rights and privileges of ownership.
Current Policy Owner(s)
Name Relationship to Insured
Address (Street)
Ownership shall be shared jointly and the consent of all joint owners will be necessary to exercise any right.
SSN/EIN Date of Birth Telephone Number
(City) (State) (Zip)
A. To one person during his or her lifetime
1. Name
Address (Street)
SSN/EIN Date of Birth Telephone Number
(City) (State) (Zip)
B. To joint owners
• If naming more than 2 owners, please attach a signed, dated sheet including all details required for each owner.
• The Social Security number or Employer Identification number of the each new owner must be shown in the appropriate
space. For tax reporting purposes, only one social security number can be used. The first owner listed will be mailed all
notices and all tax information.
• Upon the death of a joint owner, the remaining owner or joint owners shall succeed to the rights and privileges of the
deceased joint owner.
Relationship to Insured Male
Female
2. Name
Address (Street)
SSN/EIN Date of Birth Telephone Number
(City) (State) (Zip)
Relationship to Insured Male
Female
Page 1 of 4
01/21
PM6533
The Penn Mutual Life Insurance Company, Philadelphia, PA 19172
Name of Trust
Name of Trustee(s)
Address (Street)
SSN/EIN
Do not complete if the insured is the primary owner. Unless otherwise specified, this designation shall take effect upon the
death of all primary owners provided the designated contingent owner is then living and this designation has not been
revoked. Please designate the party listed below as the Contingent Owner. Select from options A or B.
Date of Trust (mm/dd/yyyy) Telephone Number
(City) (State) (Zip)
Legal Name
Address (Street)
EIN
Telephone Number
(City) (State) (Zip)
D. To the trust described below:
A. The Insured
B. To the following in his or her lifetime
• If naming more than 1 contingent owner, please attach a signed, dated sheet including all details required for each owner.
• When naming a trust as the new owner, a Certification of Trust form (PM6389) must be submitted with this form.
Contingent Owner Information (optional)
Name
Address (Street)
SSN/EIN
Premiums under this policy are to be paid by and premium notices, if any, will be sent to new owner or first owner listed on
page 1 of this form unless otherwise specified below.
Date of Birth (mm/dd/yyyy) Telephone Number
(City) (State) (Zip)
Relationship to Insured Male
Female
Name
Address (Street)
SSN/EIN Date of Birth (mm/dd/yyyy) Telephone Number
(City) (State) (Zip)
Relationship to Insured or owner
Payor Information
C. To a (check one) Corporation Partnership LLC Other
Page 2 of 4PM6533
01/21
The new policy owner may designate an authorized business representative access to policy information online by
completing a Corporate Authorization Certification form (PM8409).
Please include the Articles of Organization/Incorporation for the new owner.
Authorizations and Signatures
Owner
Individual(s) Policy Owner(s)
Corporation, Bank or Financial
Institution
Conservator, Guardian of
Estate or Power of Attorney
Agent
Trust
Partnership or LLC
Custodian on behalf of a Minor
We require UGMA or UTMA paperwork.
Signature exam
ple: John Doe, custodian for Baby Doe under (state) UTMA
If signor is unable to sign and must sign with an “X” we require signature be notarized.
We will not knowingly accept a stamped signature.
Contact customer service to verify signature(s) needed.
Signed by a “X”
Stamped signatures
All other interested parties
Signature of one officer with title, and a corporate resolution or secretary certificate
which names all officers authorized to sign on behalf of the corporation; or two officer
signatures, with title, without corporate resolution or secretary certificate.
Signature example: John Doe, President, ABC Corporation.
Signature of Conservator, Guardian of Estate or Power of Attorney Agent with title. We
require Letters of Conservatorship/Guardianship of Estate along with court order
designating conservator/guardian of estate or a copy of the Power of Attorney document
to be on file.
Signature example: John Doe, Conservator for Jane Doe.
We require one general/managing partner signature with title and a copy of the Partnership
agreement for Partnerships OR one managing member’s signature with title and a copy of
the operating agreement for LLCs.
Signature example: John Doe, Partner.
Signature of all Trustee(s) with title as authorized by the Trust documentation. We
require Trust documentation such as a Certification of Trust form (PM6389) to be on file.
If there has been a change in trustee(s) since the trust became owner, we will also
require any Resignation of Trustee or Termination of Trustee, Appointment of New
Trustee and Acceptance of New Trust documents.
Signature example: John Doe, Trustee.
Signature(s) Requirements - Please be aware that a certificate of completion must
accompany any electronic signature.
Signed on ___________ ______, __________ at ___________________________________(city) State of ________________
SigPrint Name of Current Policyowner
Print Name of Joint Policyowner
Print Name of Witness (required for state of Massachusetts)
I certify that: (1) the Taxpayer Identification number shown on this form is my correct TIN, (2) I am not subject to backup
withholding because I have not been notified by the IRS that I am subject to backup withholding, and (3) no bankruptcy or
insolvency proceeding is pending with respect to me.
Date (mm/dd/yyyy)
Sign oature f New Policy/Contract Owner
If Owner is a Corporation or Trust, provide signature and title. If multiple owners, all must sign.
New Owner's Signature Title Date (mm/dd/yyyy)
Witness Signature (required for state of Massachusetts)
nature of Current Policyowner (Please see requirements below)
Signature of Joint Policyowner (Please see requirements below)
Remarks: Please review this form for accuracy, sign the form and return it to the address below. If there is more than one
owner, all owners must sign. A confirmation of this change will be forwarded to the original policyowner(s).
Representation: The Policyowner(s) represents that no bankruptcy or insolvency proceedings are pending with respect to
Policyowner(s). General Provisions constitute a part of this designation.
The Signature of all owners will be required to exercise any contractual right under policy.
If you are signing the form in any capacity other than an individual an appropriate title is required.
Page 3 of 4
01/21
PM6533
New Policy Owner Tax Payer Certification
General Provisions
The following instructions have been enclosed to assist you with the completion of the attached Owner Designation Form.
Please read these instructions carefully before completing the application.
• Complete a separate form for each policy unless the current owner and new owner information is the same on all
policies.
• This designation applies to all policies numbered on it. This designation replaces all prior designations, including the
designation in the application to the policy, and will apply until a later designation is filed with the Company.
• Each field should be fully completed. We will not accept wording such as “same” or “no change”
• A form which has been altered or on which there has been an erasure cannot be accepted unless the alteration or
erasure is initialed by the current policy owner.
• The name and address of the individual or other entity to which future premium notices are to be sent should be
stated in the space provided. If not provided, premium notices will be sent to the new owner or first owner listed.
• An ownership change does not automatically change existing beneficiary designations. To change your beneficiary,
please submit a Penn Mutual Beneficiary designation form.
• Class Designations (such as “my lawful children” or “brothers and sisters of the insured”) cannot be used. A change in
ownership must be specific in naming the new owner.
• This form cannot be used to request a change in ownership from a qualified plan to an individual, from an individual to
a qualified plan, or from one qualified plan to another qualified plan. Please contact the home office for the correct
form(s).
• If the current owner is a company that has dissolved, then dissolution paperwork is required along with an officer’s
signature with title that is identified in the dissolution paperwork.
• If the current owner is a company that has merged with another company, we will require merger documentation
along with an officer’s signature with title accompanied by the corporate resolution or Secretary Certificate of the
merged company.
• If the new owner is a Trust, a Certification of Trust form (PM6389) must be submitted with this form.
• The Company may rely upon written evidence in its discretion to determine the identity, date of birth, name, address
or other facts concerning a policy owner.
• If you have questions about the appropriate ownership designation for your situation, you should contact your
Financial Professional for assistance.
Mailing Instructions
Please return the forms either by mail to: Or Fax to:
Penn Mutual Life Insurance Company or Penn Insurance & Annuity Company 215-956-7699
P.O. Box 178 Attention: Client Services
Philadelphia, PA 19105-0178
Page 4 of 4
01/21
PM6533
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Owner Designation Form Instructions

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Completed 9 October 2021

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