Fillable REQUEST FOR POLICY SERVICE Duplicate Contract A. BENEFICIARY

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REQUEST FOR POLICY SERVICE Duplicate Contract A. BENEFICIARY

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DO-43-1804 Page 1 of 2
THE WESTERN AND SOUTHERN LIFE INSURANCE CO.
WESTERN-SOUTHERN LIFE ASSURANCE CO.
CINCINNATI, OHIO 45202
(800) 926-1993
REQUEST FOR POLICY SERVICE
WP ORD 1600
ANNUITY
OFFICE CODE ACCT. NO. COX CONTRACT NUMBER SCOX NAME OF INSURED/ANNUITANT
INSURED DATE OF BIRTH
OWNER'S TELEPHONE NUMBER (include area code) OWNER'S ADDRESS (ZIP CODE) (SS#)
A. Beneficiary Designation B. Name Change C. Policy Certificate
Duplicate Contract
D.
Change Annuitant, Add/Change Contingent Annuitant or Change Payee
(One change per form. Do Not Key. Submit to Annuity Operations Dept – 5100.)
PLACE TRACKING
STICKER HERE
A. BENEFICIARY DESIGNATION - Completion of this form revokes all prior designations for all Classes; therefore, all Classes need to be re-
designated. For the purpose of establishing priority, Class I is higher than Class II, and Class II is higher than Class III. Child Beneficiaries: You may designate
children individually or as a group (e.g. “children of the insured”). We recommend designating children individually unless you intend to include later born or
adopted children. If you designate a group, all natural and legally adopted children in the group who are living when payment is due will be beneficiaries even if
you list individual children beneath the group designation. By designating a group, you understand and agree that the Company will be relieved of liability if it pays
a claim in good faith reliance on an affidavit or other written evidence satisfactory to the Company identifying unnamed members of the group. The SS# and Date
of Birth are not required. However, if provided, it will help locate your beneficiary quicker when a claim has been presented for processing. The Privacy Policy
Notice is available upon request. To assign beneficiary with a specified percent, list percent after beneficiary designation. PLEASE PRINT CLEARLY.
Class I (Primary)
Beneficiary Designation
SS#
Relationship to
Insured/Annuitant
Date of Birth
Address (No., Street,
City, State, Zip Code)
Class II (Contingent)
Beneficiary Designation
SS#
Relationship to
Insured/Annuitant
Date of Birth
Address (No., Street,
City, State, Zip Code)
Class III (2nd Contingent)
Beneficiary Designation
SS#
Relationship to
Insured/Annuitant
Date of Birth
Address (No., Street,
City, State, Zip Code)
Beneficiary designation is not effective unless recorded by the Company at its Home Office. A confirmation will be provided for the owner's records. Any
single sum or installment due upon or after death of the Insured/Annuitant (prior to annuitization) will be paid in equal shares, unless otherwise specified, to the
beneficiaries in the class highest in the order of priority who are living on the due date of such single sum or installment.
Remarks:
Should you (the policy owner) reside or have resided in a community property state (AZ, CA, ID, LA, NV, NM, TX, WA, WI) and your spouse has a right to the
proceeds of this policy/contract, under community property law, your spouse’s signature is required.
Date
Signature of Policy Owner Signature of Policy Owner
Date
WITNESS SIGNATURE IF SIGNED WITH AN X
A signature on this form transmitted by facsimile or electronically shall have the same force and effect as an original signature, once received the faxed document
is the controlling document.
DO-43-1804 Page 2 of 2
B. NOTICE OF CHANGE OF NAME (Do Not Submit Contract; sign at bottom)
(Do not use this form to change ownership to another person.)
Date of Birth is required for each person requiring name change.
The correct name of the
Owner (Date of Birth) ___________ Joint Owners (Date of Birth) __________
Beneficiary (Date of Birth) ____________ Spouse (Date of Birth) __________
Insured/Annuitant (Date of Birth) __________ Child (Date of Birth) __________
Is:
Reason for Change:
Mail Confirmation To Owner Yes No
Substantiate all changes (except those by Marriage, Divorce or Adoption) by attaching a copy of the Court Order or some other
authentic record.
C. POLICY CERTIFICATE (No fee required) Policy certificates are not available for issue states IL and OK.
DUPLICATE CONTRACT $25 Fee Attached? Yes No. If no fee attached, a policy
certificate will be issued.
Duplicate Contracts are not available for Weekly Premium Policies. A Policy Certificate will be issued at no charge.
By requesting a Policy Certificate or Duplicate Contract, I certify said contract has not been and is not now assigned nor has it been otherwise transferred or
encumbered in any manner whatsoever and no person, firm or corporation has or claims the right to possession of said contract.
I agree that if a Duplicate Contract is issued to me, I shall surrender and return the original contract if ever it is found; and if a Policy Certificate is issued to me,
I shall surrender and return such Certificate if the original contract ever is found.
We reserve the right to issue a Policy Certificate in situations where we cannot issue a duplicate contract. Any fees submitted will be returned.
Explain how the contract was lost or destroyed.
D. COMPLETE A SEPARATE FORM FOR EACH REQUEST.
Change Annuitant Add/Change Contingent Annuitant
Change Payee for Annuity Payments
Name Sex Date of Birth
Address SS#
City, State, Zip Relationship to Owner
Email Address Telephone #
Fax #
This change is not effective unless recorded by the Company at its Home Office. A recorded copy will be provided for the
owner's record.
Signed at Date Sign Here
CITY, STATE SIGNATURE OF OWNER
DO-43-I-1803 Page 1 of 1
Beneficiary Change
Request Instructions
Best Practices for BENEFICIARY Form Completion
ALTERATIONS
Please keep in mind that any alterations made on the form (even if initialed) will delay approval of your
request. If alterations are made, a new form without alterations will be required.
Alterations may cause a question to the validity of the request at time of claim.
To ensure your wishes are honored without delay, we will send you a new set of service forms to ensure your
wishes at time of claim can be expedited.
LOCATING BENEFICIARIES – Providing the SSN, date of birth, and address of each designated beneficiary ensures
we are able to locate and validate the beneficiary at the time of claim.
TRUST – When naming a trust as beneficiary, provide the full name of the trust and the trust date.
Note: If the trust is the owner of the policy, the trust must be the beneficiary.
FUNERAL HOME – We discourage naming a funeral home as beneficiary because 100% of the proceeds would be
payable to the funeral home regardless of the bill.
In addition, if services take place at a different funeral home, we would still be required to pay the funeral home as
designated.
Please contact us to discuss options to secure your wishes.
RELATIONSHIPS – Please note, we cannot accept relationships such as caregiver, guardian, attorney-in-fact,
banker, trustee, executor, etc., because they may not be acting in that capacity at time of claim.
DISTRIBUTION REQUESTS – Distribution requests must be within the same class designation and add to 100%.
We cannot accept dollar amounts as the death benefit could be reduced by withdrawals such as loans, dividends,
and premium payments due.
CHANGING/CORRECTING NAMES – Complete Section B for any changes you wish to make to individuals named
on the existing policy record due to marriage, adoption, spelling, or legal name changes; and provide the requested
identifying data.
Please note: Section B is not for changing the actual individual on record to a different individual.
LEGAL REPRESENTATIVES – If a power of attorney or guardianship is involved, the signature must include the
legal title following the signature. Please submit the legal documents to show the authority for making these
changes, including a court order authorizing change if a guardianship is involved.
DATING FORM – We must have full current dates (month/day/year); incomplete dates, no dates, or
post/advanced dates will result in delaying approval of your service request.
The dates on the service forms, just like the signatures, validate the requests made by you and the new policy
owner.
Be sure to return the form for processing using one of the methods below:
Mailing Address:
PO Box 1119 Cincinnati, OH 45201-1119
Faxing:
513-629-1530
E-mail
wspsforms@wslife.com
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REQUEST FOR POLICY SERVICE Duplicate Contract A. BENEFICIARY

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Completed 15 February 2021

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