Page 2 of 2 - Incomplete without all pages. Order #131457 07/01/2020
Owner Signature Date
Spouse Signature
1
Date
Irrevocable Beneficiary Signature
(if applicable)
Date
Agent Signature
(Optional)
Date
1
Completion of Section F or a Spouse signature is required if the owner lives in a community property state (AZ, CA, ID, LA, NM, NV, TX, WA or WI).
Reminder to Producer regarding New York Issued Contracts: Before making any recommendation, you must have adequate knowledge of the transaction
you’re recommending and provide your client with the relevant features of the contract and potential consequences of the transaction, both favorable and
unfavorable. If you have any questions about the contract or transaction prior to making a recommendation, contact the Company.
Note to Owner regarding New York Issued Contracts: If your producer is providing a recommendation regarding this transaction, the producer is required
to provide you with the relevant features of the contract and potential consequences of the transaction, both favorable and unfavorable.
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid
backup withholding.
E. CHRONIC ILLNESS ACCELERATED DEATH BENEFIT RIDER NOTICE
(Applicable to policies with the Chronic Illness Rider.)
G. US TAXPAYER CERTIFICATIONS
By your signature below, you acknowledge that certain changes to your policy or riders may terminate the Chronic Illness Accelerated Death Benefit Rider
(“Rider”). For example, loans, partial withdrawals, death benefit option changes, coverage increases and decreases, and benefit payments on any other
accelerated death benefit rider under the same policy may terminate Rider benefits. Refer to the Rider for detailed information and contact your producer
with questions about your policy.
H. SIGNATURES
F. COMMUNITY PROPERTY STATE REQUIREMENTS
(If the owner currently lives in a community property state (AZ, CA,
ID, LA, NM, NV, TX, WA or WI), a spouse signature is required unless one of the two areas are completed below. Failure to provide
a spouse signature or the completion of this section will result in a delay in completing the requested change.)
Assignee Signature
(if applicable)
Date
Assignee Name
(Print full name of individual or entity. If an entity, attach corporate resolution or similar document listing authorized signatories.
If entity has had a name change, include supporting documentation of successor in interest with listing of authorized signatories.)
Owner Title
(If the owner is a trust, partnership, or corporation, a signature is required from an ocer, partner, corporate representative or
authorized corporate representatives. If a trust, partnership or corporation, attach corporate resolution or Trust Certification. If entity
has had a name change, include supporting documentation of successor in interest with listing of authorized signatories.)
Irrevocable Beneficiary Title
(If the owner is a trust, partnership, or corporation, a signature is required from an ocer, partner, corporate
representative or authorized corporate representatives. If a trust, partnership or corporation, attach corporate
resolution or Trust Certification. If entity has had a name change, include supporting documentation of successor in
interest with listing of authorized signatories.)
Under penalties of perjury, I certify that:
1. The Taxpayer Identification Number that appears on this form is correct.
2. I am not subject to backup withholding due to failure to report interest and dividend income;
c If I am subject to backup withholding, I have checked here.
3. I am a U.S. person.
NON-RESIDENT ALIEN STATUS
If you are a Non-Resident Alien, check the box and provide your country of residence below.
c Under penalties of perjury, I certify that I am a Non-Resident Alien and my country of residence is: .
The amount paid to you will be subject to 30% withholding, unless you submit an IRS Form W-8, and are entitled to claim a reduced rate of withholding under
the applicable US tax treaty.
• If never married, initial here.
• If deceased, indicate Date of Death of Spouse
• If divorced, this section must be completed. Check the box below and provide the Date of Divorce.
c I confirm that I am no longer married. Date of Divorce
I understand that the Company is not a party to my divorce decree or marriage settlement agreement and that I am responsible for any requirements included
in these documents. Additionally, I understand that my failure to comply with property settlement requirements involving my divorce may give rise to a claim
against my estate in the future.
