Fillable Ownership Change and Beneciary Designation Instructions and Guidelines (Genworth)

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Ownership Change and Beneciary Designation Instructions and Guidelines (Genworth)

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Ownership Change and Beneficiary Designation
Instructions and Guidelines
GNWOwnBen INST 12/13/13
Genworth Life and Annuity Insurance Company, Richmond, VA
Genworth Life Insurance Company, Richmond, VA
Genworth Life Insurance Company of New York, New York, NY
Only Genworth Life Insurance Company of New York is admitted in and conducts business in New York.
Please follow these instructions carefully when submitting
a form to prevent any delays caused by unclear or
missing information. Be sure to read and fill out the form
completely and return all pages. This instruction page
does not need to be returned to us.
General Guidelines
1. Print clearly! Cross-through, initial and date any
corrections or changes. Do not use correction fluid.
2. We require a specific version of the form if your policy
was delivered in LA, MD, ME, NH, OH, VA, VT or WA. Be
sure you are using the correct version for your requests.
3. Ownership changes may have tax consequences.
Contact your tax or legal advisor to discuss your specific
needs.
4. The Certification of Trustee Powers section must
be completed for any trust designated as owner or
beneficiary.
5. Please allow 7-10 business days processing time. After
receipt of your properly completed form, we will send
written confirmation of the change.
Ownership Changes
1. If the owner is changed, any contingent owner is
automatically revoked and must be restated.
2. An ownership change revokes any prior electronic funds
transfer (EFT) authorization. To continue EFT, you must
complete the EFT section and the bank account owner
must sign the authorization on page 2.
3. Answer the U.S. citizen question and provide the
Permanent Resident Card or Visa number if applicable
for any individual designated as owner.
4. Complete the Business information section for any
business designated as owner.
Beneficiary Changes
1. A beneficiary change revokes all prior beneficiary
designations. You must restate the primary beneficiary
in the primary beneficiary section, even if you only want
to change or add a contingent beneficiary.
2. If you wish to designate more than four beneficiaries
attach a signed and dated sheet listing additional
beneficiaries including all details as indicated in
Beneficiary Designation section.
Signatures
1. Please review and follow the instructions below carefully,
to ensure your request is not delayed.
2. Be sure to have all required parties sign in their capacity
or with title as required.
3. Be sure to review all requirements below and submit any
additional documentation as required.
Attorney-in-Fact
The attorney-in-fact or Agent must sign in capacity as “attorney-in-fact” or
“Agent”, provide a copy of the entire power of attorney document (if not
previously submitted), and complete and submit a Genworth Declaration
of attorney-in-fact form. An updated Declaration of attorney-in-fact form is
required every 12 months if the power of attorney is durable, otherwise an
updated form is required with each request submitted.
Corporation or Limited Liability Corporation (LLC)
An officer of the company or member of the LLC must sign with title (if the
signing officer or member is also the insured/annuitant, a second officer or
member must also sign), and provide either a corporate or board of director’s
resolution, a copy of the Articles of Incorporation or operating agreement (for
LLCs), or complete the corporate acknowledgement and sign the form in the
presence of a Notary Public.
Guardian
The guardian must sign in capacity and provide a copy of the guardianship
documents if not previously submitted.
Irrevocable beneficiary
The individual, trustee or representative must sign with the title “Irrevocable
Beneficiary”.
Joint owners
All owners must sign.
Partnership
All partners must sign with title, or the general or managing partner must
sign with title (if the general or managing partner is also the insured/
annuitant, another partner must also sign).
Spouse
A spouse in a community property state (AZ, CA, ID, LA, NV, NM, TX, WA, WI)
must sign.
Trust
The trustee(s) must sign with title “trustee,” according to the terms of the
Trust Agreement, and complete the Certification of Trustee Powers section if
not previously submitted.
Witness
A witness (over 18 years of age) must sign for all life insurance beneficiary
changes when the owner resides in Massachusetts.
Genworth, Genworth Financial and the Genworth logo are registered service marks of Genworth Financial, Inc. © 2013 Genworth Financial, Inc. All rights reserved.
ICC14-OwnBen 05/01/14
Policy number Use only the spaces needed
▪
Ownership and beneficiary designation
request for life insurance policies
○ Genworth Life and Annuity Insurance Company (GLAIC)
○ Genworth Life Insurance Company (GLIC)
Page 1 of 3
Section I– Policy information
Section II– Ownership change
• An ownership change revokes all third party notications, all existing revocable beneciary designations and all existing settlement options. The new
owner becomes the beneciary unless a beneciary is designated by this form, or there is an existing irrevocable beneciary.
• An ownership change revokes any existing Electronic Funds Transfer (EFT) authorization. To continue making EFT withdrawals, the new owner must
complete the Electronic Funds Transfer (EFT) section on page 2.
Insured Name
▪
Insured Birth Date
▪
Insured SSN
▪
Insured Telephone Number
▪
Insured Mailing Address
▪
Current Owner Name
▪
Owner birth/trust date
▪
Owner SSN
▪
Owner Telephone Number
▪
Owner Mailing Address
▪
New primary owner Only the primary owner will receive premium notices and policy notifications.
Type of owner Select one ○ Individual
○
Business Complete business information below
○ Trust Complete Certification of trustee powers on page 3
Relationship to Insured
▪
New primary owner name/trust name
▪
Birth/trust date
▪
SSN/TIN
▪
Telephone Number
▪
Mailing Address
▪
U.S. Citizen
○ Yes ○ No*
*If no, provide Permanent Resident Card or Visa number
▪
New joint owner Joint owners will have right of survivorship unless otherwise designated or stated in your policy.
Business information Complete this section for any business designated as primary or joint owner.
New contingent owner Contingent owner becomes primary owner if all primary and joint owners are deceased.
Full legal name of business
▪
Type of business Select one
○ Corporation
○
General Partnership
○
Sole Proprietor
○ Limited Liability Company
○
Limited Liability Partnership
○ Other
Capacity of authorized person Select one
○ CEO/President/Chairman
○
Managing member(s)
○
Managing/General partner(s)
○ Owner
○ Other
Authorized person(s)
▪
Purpose of business
▪
Incorporation/formation date
▪
Incorporation/formation State/Country
▪
Type of owner Select one ○ Individual
○
Business Complete business information below
○ Trust Complete Certification of trustee powers on page 3
Relationship to Insured
▪
New joint owner name/trust name
▪
Birth/trust date
▪
SSN/TIN
▪
Telephone Number
▪
Mailing Address
▪
U.S. Citizen
○ Yes ○ No*
*If no, provide Permanent Resident Card or Visa number
▪
Type of owner Select one ○ Individual
○
Business Complete business information below
○ Trust Complete Certification of trustee powers on page 3
Relationship to Insured
▪
New contingent owner name/trust name
▪
Birth/trust date
▪
SSN/TIN
▪
Telephone Number
▪
Mailing Address
▪
U.S. Citizen
○ Yes ○ No*
*If no, provide Permanent Resident Card or Visa number
▪
291771
Genworth Life and Annuity
Genworth Life
P.O. Box 40016
Lynchburg, VA 24506-4016
Tel: 888 436.9678
Fax: 877 300.1280
Ownership and beneficiary designation request
Page 2 of 3
ICC14-OwnBen 05/01/14
1.
To designate more than 4 primary or 2 contingent beneciaries, or for designations that require more space, attach a separate sheet with all designation
requirements and policy number. The sheet must be signed and dated with the same date as this form.
Percentages MUST total 100%
Section III – Beneficiary designation
All beneficiary changes MUST include the designation of a Primary beneficiary. Even if you only want to change the Contingent beneciary, you must
restate the Primary beneciary in the Primary beneciary section. Designations must be made in percentages. If not stated, designations will be made in
equal shares.
Primary beneficiary full legal name
▪
Birth/trust date
▪
SSN
▪
Telephone Number
▪
Mailing Address
▪
Relationship to Insured
▪
Percent
▪
2.
Primary beneficiary full legal name
▪
Birth/trust date
▪
SSN
▪
Telephone Number
▪
Mailing Address
▪
Relationship to Insured
▪
Percent
▪
3.
Primary beneficiary full legal name
▪
Birth/trust date
▪
SSN
▪
Telephone Number
▪
Mailing Address
▪
Relationship to Insured
▪
Percent
▪
4.
Primary beneficiary full legal name
▪
Birth/trust date
▪
SSN
▪
Telephone Number
▪
Mailing Address
▪
Relationship to Insured
▪
Percent
▪
1.
Contingent beneficiary full legal name
▪
Birth/trust date
▪
SSN
▪
Telephone Number
▪
Mailing Address
▪
Relationship to Insured
▪
Percent
▪
2.
Contingent beneficiary full legal name
▪
Birth/trust date
▪
SSN
▪
Telephone Number
▪
Mailing Address
▪
Relationship to Insured
▪
Percent
▪
Percentages MUST total 100%
Section IV – Electronic Funds Transfer (EFT) authorization
By signing, you (the bank account owner) understand and accept these terms and conditions:
- You authorize us to withdraw the scheduled premium payments from your account
- A premium is considered paid only if the draft is honored by your nancial institution
- We may discontinue withdrawals at any time and bill you directly
- You must contact us at least three business days before a scheduled withdrawal to
change or cancel this authorization
- You must notify us within 60 days of any mistakes in the Electronic Funds Transfer
Bank account owner name(s)
▪
Financial institution name
▪
Payment frequency** Select one
○ Monthly* ○ Quarterly ○ Semi-Annually ○ Annually
*We may initially draft two payments to make sure your
coverage is up to date.
Bank account owner mailing address
▪
Routing number (see A)
▪
Checking account number (see B)
▪
Payment amount authorized (if other than scheduled premium
amount) $
If the bank account is owned by someone other than the policy owner, the bank account owner(s) must sign authorizing the Electronic Funds Transfer (EFT).
A
B
**For most products, there is an additional cost if you pay premiums more often than annually.
123456789
Ownership and beneficiary designation request
Page 3 of 3
ICC14-OwnBen 05/01/14
Section V – Certification of trustee powers
• Complete the section for any trust designated as owner or beneciary.
• If more space is needed, attach a separate sheet of paper, signed and dated the same as this form.
Trust title Example: “Jones Family Trust”
▪
Trust date
▪
Last amended
▪
Tax ID (TIN)
▪
Trustee name and address
▪
Trustee name and address
▪
Transaction requests must be authorized by Select one
○ Any one trustee ○ All trustees ○ A majority
Is this a Grantor trust?
○ Yes* ○ No
Trust information
Grantor name
▪
SSN
▪
Address
▪
Grantor name
▪
SSN
▪
Address
▪
Grantor trust information *If yes, complete the Grantor Trust information below (IRC
§§
671-679)
Control of trust and trustee These questions must be answered
1. Is the trust or owner identied above, or are you, acting under the control
or direction of another person(s) or entity with respect to the policy identied in this form?
2. If Yes, please answer the following questions. If none, state “none.”
a. Identify the person(s) or entity under whose control or direction the trust is or you are acting:
b. Describe the nature or extent of such control or direction:
c. Provide an explanation of the source of funds used to pay premiums for the policy:
3. Please identify the following. If none, state “none.”
a. The person or entity, if any, that has the power to remove you as trustee:
b. The person or entity, if any, that has the power to change beneciary(ies) of the trust:
○
Yes ○
No
Section VI – Signatures See instructions page for signing instructions and documentation requirements.
If you are signing as other than an individual, you must indicate capacity and provide required certication or documentation. By signing, you:
• Represent that you have the authority as the owner or in the capacity indicated to exercise the rights, privileges, options and benets under the policy listed;
and you understand and agree that we are not obligated to verify that you are acting within your approved authority when you exercise these rights;
• Jointly and severally indemnify and hold us harmless from any liability for acting according to your instructions; and
• Agree to inform us in writing of any change in the information provided in this form.
• Represent that the statements and answers given on this form are true, complete and correct to the best of your knowledge and belief
• Declare that no bankruptcy proceedings are now pending against you and you are not subject to back-up withholding
• Understand that the designations on this form will not be effective unless all designation requirements are completed.
• In states requiring that an insurable interest exist on the transfer of life insurance policies, you
- Agree that only those who have an insurable interest in the life of the Insured are now, can or will be beneciaries of the policy or trust
- Have not, and will not, transfer for consideration any interest in the policy to any party who has no insurable interest in the Insured.
Current owner Required
X
Date
▪
Capacity If applicable
○ Trustee ○ Guardian ○ Attorney-in-Fact ○ Title/officer:
Joint owner If applicable, required
X
Date
▪
Capacity If applicable
○ Trustee ○ Guardian ○ Attorney-in-Fact ○ Title/officer:
New owner Required
X
Date
▪
Capacity If applicable
○ Trustee ○ Guardian ○ Attorney-in-Fact ○ Title/officer:
New Joint owner If applicable, required
X
Date
▪
Capacity If applicable
○ Trustee ○ Guardian ○ Attorney-in-Fact ○ Title/officer:
Other If applicable
X
Date
▪
Capacity If applicable
○ Trustee ○ Guardian ○ Attorney-in-Fact ○ Title/officer:
Other If applicable
X
Date
▪
Capacity If applicable
○ Trustee ○ Guardian ○ Attorney-in-Fact ○ Title/officer:
Other If applicable
X
Date
▪
Role If applicable ○ Bank account owner ○ Witness (MA only)
○ Collateral Assignee ○ Irrevocable Beneficiary
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Ownership Change and Beneciary Designation Instructions and Guidelines (Genworth)

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Completed 24 April 2021

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