Applications

Individual & Family Plan Applications

California

ABA Form (Transfer to Trustee)
Absolute Assignment (AGLC0010) – 1035 exchange
Accident Expense Plus Application – Nationwide
Addendum to Part A or B application
Affidavit Naming Children as Insured
Affidavit of Heirship
Agent Certification Form
Annuitization Request
Annuity Claimant Statement
Aviation Questionnaire – Nationwide
Avocation Questionnaire – Nationwide
Bank Draft Authorization RB 5-28-10
Business Financial Questionnaire
Certification of Taxes and Laws for Foreign National and Visa Holders
Change of Beneficiary
Change of Ownership
Collateral Assignment
Collateral Assignment Form
Collateral Assignment Form – Annuities
Commercial Insurance Solicitation Record – Military
Credit Card Authorization – Initial Premium ONLY
Disability Income Continuation Form – Generic
Disclosure for Sales to Senior Citizens – CA
Disclosure for Term Life Insurance (AGL) – CA & SC
Disclosure Form for Military Sales
Drug/Alcohol Questionnaire – Nationwide
Electronic Funds Transfer Authorization – EFT
Employer’s Statement Total Disability Benefits
Exempt Employee Certification – CA
Financial Institution Source of Funds Certification
Financial Institution Source of Funds Certification
Financial Products Disclosure – CA
Financial Questionnaire – Nationwide
Foreign Travel or Residence Supplement – Nationwide
HIPAA Authorization – Claim
HIPAA Authorization – Claim (CA)
HIPAA Authorization – Life New Business
HIPAA Privacy Notice – REV0311
HIPPA Authorization – CA
HIV Testing Consent – CA
How to Convert Group to Individual
Illustration Acknowledgement and Certification
In-Force Change Application – CA
Lien Agreement
Life Application Part A – CA
Life Application Part B – CA
Life Insurance Information for Military Personnel
Limited Power of Attorney
Medi-Cal Eligibility Notice Regarding Standards for Senior Citizens
Name and Address Change
Outline of Coverage for Disability Income Rider – Generic
Personal Commercial Solicitation Evaluation – Military
Personal Financial Questionnaire
Policy Delivery Receipt – AGL version
Premium Financing Disclosure for Proposed Insureds
Proof of Heirship Affidavit Statement
Reinstatement Application – CA
Replacement Form – CA
Replacement Form – CA, IL, NE, NM, NC, OH
Replacement Instruction Sheet
Replacement Policies and Guidelines – D (agent only)
Request for Direct Rollover
Required Minimum Distribution Election Form
ROTH IRA Acknowledgment
Salary Allotment – Employer’s Acceptance of Plan
Salary Allotment Authorization
Salary Reduction Agreement
Service Request
Service Request
Short Health Statement – Nationwide
Supplemental Deferred Annuity Application
Systematic Premium Preauthorized Debit Form
Systematic Withdrawal Request
Term Application Part A – CA
Term Child Rider Attachment – Generic
Term Conversion Request Form
Transmittal Form – Split Dollar Checklist
Transmittal Form and Checklist – IAG and LBG
ABA Form (Transfer to Trustee)
Absolute Assignment (AGLC0010) – 1035 exchange
Accident Expense Plus Application – Nationwide
Addendum to Part A or B application
Affidavit Naming Children as Insured
Affidavit of Heirship
Agent Certification Form
Annuitization Request
Annuity Claimant Statement
Aviation Questionnaire – Nationwide
Avocation Questionnaire – Nationwide
Bank Draft Authorization RB 5-28-10
Business Financial Questionnaire
Certification of Taxes and Laws for Foreign National and Visa Holders
Change of Beneficiary
Change of Ownership
Collateral Assignment
Collateral Assignment Form
Collateral Assignment Form – Annuities
Commercial Insurance Solicitation Record – Military
Credit Card Authorization – Initial Premium ONLY
Disability Income Continuation Form – Generic
Disclosure for Sales to Senior Citizens – CA
Disclosure for Term Life Insurance (AGL) – CA & SC
Disclosure Form for Military Sales
Drug/Alcohol Questionnaire – Nationwide
Electronic Funds Transfer Authorization – EFT
Employer’s Statement Total Disability Benefits
Exempt Employee Certification – CA
Financial Institution Source of Funds Certification
Financial Institution Source of Funds Certification
Financial Products Disclosure – CA
Financial Questionnaire – Nationwide
Foreign Travel or Residence Supplement – Nationwide
HIPAA Authorization – Claim
HIPAA Authorization – Claim (CA)
HIPAA Authorization – Life New Business
HIPAA Privacy Notice – REV0311
HIPPA Authorization – CA
HIV Testing Consent – CA
How to Convert Group to Individual
Illustration Acknowledgement and Certification
In-Force Change Application – CA
Lien Agreement
Life Application Part A – CA
Life Application Part B – CA
Life Insurance Information for Military Personnel
Limited Power of Attorney
Medi-Cal Eligibility Notice Regarding Standards for Senior Citizens
Name and Address Change
Outline of Coverage for Disability Income Rider – Generic
Personal Commercial Solicitation Evaluation – Military
Personal Financial Questionnaire
Policy Delivery Receipt – AGL version
Premium Financing Disclosure for Proposed Insureds
Proof of Heirship Affidavit Statement
Reinstatement Application – CA
Replacement Form – CA
Replacement Form – CA, IL, NE, NM, NC, OH
Replacement Instruction Sheet
Replacement Policies and Guidelines – D (agent only)
Request for Direct Rollover
Required Minimum Distribution Election Form
ROTH IRA Acknowledgment
Salary Allotment – Employer’s Acceptance of Plan
Salary Allotment Authorization
Salary Reduction Agreement
Service Request
Service Request
Short Health Statement – Nationwide
Supplemental Deferred Annuity Application
Systematic Premium Preauthorized Debit Form
Systematic Withdrawal Request
Term Application Part A – CA
Term Child Rider Attachment – Generic
Term Conversion Request Form
Transmittal Form – Split Dollar Checklist
Transmittal Form and Checklist – IAG and LBG
Accordion Sample DescripAcknowledgement of Disclosure for Employer-Owned Life
Insurance Policies
Application For Individual Life Insurance (Section A & D) (nonn-ICC)
AXA Advisors Privacy Policy
Captive Insurer Acknowledgement & Hold Harmless Form
Disclosure for commercial financed life policies
DISCLOSURE FOR EMPLOYER-OWNED LIFE INSURANCE POLICIES
Financial Questionnaire (Section C) non-ICC
Financial Supplement II
Guaranteed Issue Life Application – CA
HIPAA Authorization
HIPAA Release Information (non-ICC)
HIV Test Consent
Instructions for New Life Application
Language Barrier Statement for Agent
Life Insurance and Annuity Disclosure to Active Duty Members of the Armed Forces
Limited Temporary Insurance Agreement/Receipts (non-ICC)
Living Benefits Rider Brochure
Living Benefits Rider Brochure
No Conforming Illustration Certificate
NOTICE AND CONSENT FORM FOR EMPLOYER OWNED LIFE INSURANCE
Owner Questionnaire (Section C) non-ICC
Request for Systematic Plan
Term LIfe-Product Information (Section B) non- ICC
Underwriting Page (non-ICC)
Variable Universal Life Supplement
Variable Universal Life Supplementtion
3rd Party Translator’s Statement
Acknowledgement of Non-Illustrated Application
Additional Details Supplement to Application (Part I)
Additional Details Supplement to Application (Part II)
California Applicant (65 Years or Older) Verification of Disclosure Statements
California Disclosure Notice to Persons Age 65 and Older
Conditional Receipt
First Financial Inspection Request
Life Insurance Application (CA)
Notice and Consent for Blood Testing (CA)
Privacy Policy – Explanation
Release of Health-Related Information – HIPAA Privacy
1035 Exchange Agreement
Application
Application Overflow
Authorization for Release of Health-Related Information
Certification of trustee powers
Computer screen illustration waiver acknowledgment
Consumer Complaints Listing
Declaration of attorney-in-fact
Disclosure Statement (Term only) (CA)
Disclosure Statement (UL only)
Electronic fund transfer (EFT) authorization (Policyholder Services)
Electronic Fund Transfer Authorization (EFT) (New Business)
Employer life insurance application addendum (Qualified Plans)
HIV Consent
HIV Consent (CA)
HIV Counseling (CA)
IGO APP QUICKCHECK GUIDE
Illustration waiver acknowledgement
Joint Life Application
Notice and Consent to Employer’s Application for Life Insurance
Notice Regarding Standards for Medi-Cal Eligibility
Personal Commercial Solicitation Evaluation
Premium Financing Disclosure Statement
Required disclusures regarding sales to military personnel
Statement Regarding Sales Outside Owner Resident State
Statement Regarding Sales Outside Owner Resident State
Supplement to Life Application Part I
Verification of Disclosures to California Residents 65 and Older
1035 Exchange Agreement
Application
Application Overflow
Authorization for Release of Health-Related Information
Certification of trustee powers
Computer screen illustration waiver acknowledgment
Consumer Complaints Listing
Declaration of attorney-in-fact
Disclosure Statement (Term only) (CA)
Disclosure Statement (UL only)
Electronic fund transfer (EFT) authorization (Policyholder Services)
Electronic Fund Transfer Authorization (EFT) (New Business)
Employer life insurance application addendum (Qualified Plans)
HIV Consent
HIV Consent (CA)
HIV Counseling (CA)
IGO APP QUICKCHECK GUIDE
Illustration waiver acknowledgement
Life Quick Request Agent Worksheet
Life Quick Request Temporary Insurance Application and Agreement (TIAA) Worksheet
Life Quick Request Worksheet
Notice and Consent to Employer’s Application for Life Insurance
Notice Regarding Standards for Medi-Cal Eligibility
Personal Commercial Solicitation Evaluation
Premium Financing Disclosure Statement
Quick App Fulfillment Worksheet – Overflow
Required disclusures regarding sales to military personnel
Statement Regarding Sales Outside Owner Resident State
Statement Regarding Sales Outside Owner Resident State
Supplement to Application – Mortgage Certification
Supplement to Life Application Part I
Verification of Disclosures to California Residents 65 and Older
Administrative Form for Universal Life Insurance
Application for Life Insurance
Authorization for Release of Information-CA (HIPAA & MIB)
Backdating Letter
California Aids Counseling Facilities
Disclosure Form for Lincoln LifeElements Level Term (2009)
Disclosure Notice to Persons Age 65 and Older-CA
Disclosure Statement Required with Flexible Premium-CA
Disclosure Statement-ABR
Disclosure Statement-ABR
Disclosure Statement-ABR
Disclosure Statement-CA
Disclosure-Universal Life-CA
Electronic Funds Transfer (EFT) Authorization
Employer Owned Life Insurance Consent and Notice
Financial Institution Disclosure Notice
HIV Infection and AIDS: An Overview
Illustration Compliance Certification Form
Life Insurance Buyers Guide
Military Sales Disclosure
Notice and Consent for HIV-Related Testing
Out-of-State Sale Verification Form
Premium Financing Lender Certification
Premium Financing Supplement-CA
Privacy Practices Notice
Required Producer & Representative Certification Regarding SOLI
Short Form Request for Individual Tax Return Transcript
Temporary Life Insurance Agreement
1035 Exchange
CA Elder Law Notice
CA Senior Notice
Certification of Trust Agreement
COLI Consent Form
Consumer Protection Notice
Credit Card Billing Authorization
Disclosure for IUL
Disclosure Form – Guarantee No Lapse Provision (UL) (CA)
Electronic Fund Transfer Authorization
HIV Consent (CA)
IUL Disclosure
IUL Supplement to Application
Life Agent Report
Life Application Part I B (CA)
Life Insurance Application (CA)
NAC HIPAA Authorization
Pension Max Disclosure Statement
Policy Settlement Agreement – Beneficiary Designation
Red Cross HIV Testing Brochure
SIUL App for Election of Accelerated Benefits
SIUL Benefit Worksheet and Payment Notice
Statements About Illustrations
Temporary Insurance Agreement
Transmittal Report
Application Packet – Brokerage Life Insurance
Authorization to Obtain and Disclose Information (HIPAA)
Authorization to Release Underwriting Information
Broker/Representative’s Report
California NOTICE REGARDING STANDARDS
Conditional Receipt / Temporary Life Receipt Agreement
Confidential Financial Statement
Consent and Authorization to Obtain and Disclose Information
Critical Illness Application (CA)
Disclosure and Acknowledgement (Replaces 9/08 version)
Election of Paid-Up Endowment Option
Electronic Policy Delivery Form
HIPAA Compliant Authorization to Release Confidential Medical Information
Income Provider Option
Informal Inquiry
Landmark Drawing Copy Test
MIB Disclosure (CA)
Military – Personal Commercial Solicitation Evaluation
Military DA Form 2056
Military Questionnaire (Generic)
Military Sales Disclosure Form
NAIC No Illustration Form (CA)
Non-Licensed Territory Declaration (New York)
Notice and Consent for HIV/AIDS Testing (CA)
Notice Regarding Save-Age Dating of Policy
Notice to Applicants Aged 65 or Older
Other Kaiser or Medical Institutional Forms (CA)
Other Kaiser or Medical Institutional Forms (CA)
Other Kaiser or Medical Institutional Forms (CA)
Other Kaiser or Medical Institutional Forms (CA)
Other Kaiser or Medical Institutional Forms (CA)
Pre-Authorized Withdrawal
Sample Notice and Consent Document for Employer-Owned Life Insurance
Statement of Owner Intent
SUPPLEMENT TO LIFE INSURANCE APPLICATION
Supplemental Application Large Case
Tax Treatment of Modified Endowment Contracts (MEC)
TeleLife Application Fax Pre-App
Trust Certification
UL Disclosures
UL Disclosures (CA)
UL Disclosures (CA)
Underwriting Transmittal
Written Notice to California Seniors Aged 65 or Over
2010 Application Authorization – Stand-alone
2010 Application for Life Insurance – GENERIC
2010 Important Notice About Your Application for Life Insurance – Stand-alone
2010 Instructions For Completion of Application for Life Insurance – GENERIC
2010 Instructions for Completion of Xpress Package – GENERIC
2010 Prudential Xpress Quickform
2010 What to Expect Next
2011 Individual Agent’s Report – Stand-alone
2011 Juvenile Agent’s Report – Stand-alone
Agent’s Report – Survivorship Application
Application for Survivorship
Application for Variable Universal Life
Authorization to Disclose Medical Information
HIV Consent Form – CO
Important Notice Regarding Replacement
Notice Regarding Modified Endowment Contracts
PREPAID CASES ONLY. 2010 Limited Insurance Agreement – Stand-alone
Request for initial Premium (E-PAY)
Accelerated Benefit Rider Disclosure
Accelerated Benefit/Living Benefit Rider Disclosure – (Generic UL & VUL)
Acknowledgement in Lieu of Illustration
Age 71+ Questionnaire
Application for Life Insurance – fillable – UL or VUL
Blood Consent
California Assembly Bill 2107 Disclosure (ages 65 plus)
CHIRA® Acknowledgement and Disclosure
Credit Card Authorization/EFT Request
ERISA DISCLOSURE AND ACKNOWLEDGEMENT
Formal New Business Transmittal Checklist
Fund Allocation of Premium Payments Supplement
Fund Allocation of Premium Payments Supplement
Government / Military Allotment
Guaranteed Benefit Policy Acknowledgement
ING ROP Endowment Term Life Insurance – Supplement to Application
Initial Payment Credit Card Authorization Request
Living Benefit Rider Disclosure
Military Disclosure – Personnel Financial Services Disclosure Regarding Insurance Products
Notice of Life or Annuity Sales Visit (CA)
NOTICE REGARDING STANDARDS (CA)
Out of State Verificatioin
Premium Financing Disclosure
Release of Waiver of Liability Agent as Fiduciary
Telephone Authorization for VUL Policies
Term Life Insurance Application – fillable (AR,CA,CT,DE,MT,ND,SD,GU)
Underwriting Personal Financial Questionnaire
Underwriting Personal Financial Questionnaire
Underwriting Personal Financial Questionnaire
Underwriting Personal Financial Questionnaire
 PRODUCT SUITABILITY FORM
ACCELERATED BENEFIT INSURANCE RIDER DISCLOSURE STATEMENT
ACCELERATED BENEFIT INSURANCE RIDER DISCLOSURE STATEMENT
ACCELERATED BENEFIT INSURANCE RIDER DISCLOSURE STATEMENT
ACCELERATED BENEFIT INSURANCE RIDER DISCLOSURE STATEMENT
ACCELERATED BENEFIT INSURANCE RIDER DISCLOSURE STATEMENT
ANNUITY APPLICATION
ANNUITY APPLICATION
CA ELDER DISCLOSURE
CERTIFICATE IN LIEU OF ILLUSTRATION
DISCLOSURE STATEMENT
DISCLOSURE SUPPLEMENT TO APPLICATION
HIV CONSENT FORM (Upon Request)
HOME MEETING NOTICE (Age 65 and older)
LIFE APPLICATION
LIFE APPLICATION
LIFE INSURANCE APPLICATION (ages 15 days – 17 years, face amounts $25,000 to $100,000)
LIFE INSURANCE APPLICATION (Full Underwriting Application)
LIFE INSURANCE APPLICATION – PART 1
LIFE INSURANCE APPLICATION – PART 2 (Do Not Complete, will of tele-interview)
PRODUCT SUITABILITY
STRATEGY DISCLOSURE FORM
Agent Certification
AIDS Notification and HIV testing consent form
Application Amendment for Juvenile
Conditional Receipt Agreement
FDIC Notice to Insurance Customers
Financial Supplement
Life Insurance and Annuity Disclosure for Applicants 65 years of age and older
Life Insurance Application – Part One
Military Sales Disclosure
No Sales Illustration Certification
Notice and Consent form Employer-Owned Life Insurance
Notice to Producer
Notice to Producer
Notice to Proposed Insured and Owner
Notice to Senior of a Life Insurance or Annuity Sales Visit (CA)
Supplement to Life Insurance Application Part I
Surrender/Exchange Application Supplement
Transmittal Form
Accelerated Benefit Rider Disclosure
Accelerated Death Benefit Rider Disclosure
Acknowledgement in Lieu of Illustration
Age 71+ Questionnaire
Application for Life Insurance – fillable – UL or VUL
Blood Consent
California Assembly Bill 2107 Disclosure (ages 65 plus)
CHIRA® Acknowledgement and Disclosure
Corporate-Owned Life Insurance (COLI) California Insurance Code Section 10110.4
Certification
Election Worksheet
ERISA DISCLOSURE AND ACKNOWLEDGEMENT
Formal New Business Transmittal Checklist
Fund Allocation of Premium Payments Supplement
Government / Military Allotment
Guaranteed Benefit Policy Acknowledgement
ING IUL-Global Plus Disclosure Supplement (Most states)
M-Financial Fund Allocation of Premium Payments Supplement
Military Disclosure – Personnel Financial Services Disclosure Regarding Insurance Products
Notice of Life or Annuity Sales Visit (CA)
NOTICE REGARDING STANDARDS (CA)
Out of State Verificatioin
Premium Financing Disclosure
Release of Waiver of Liability Agent as Fiduciary
Telephone Authorization for VUL Policies
Term Life Insurance Application
Underwriting Personal Financial Questionnaire
Underwriting Personal Financial Questionnaire
Underwriting Personal Financial Questionnaire
Underwriting Personal Financial Questionnaire
Application for Life Insurance
Buyer’s Guide
HIPAA Authorization – Generic & CA
HIV Consent
Life Insurance Application – CA
Supplement to Application
Supplement to Application
Terminal Illness Disclosure Form
Addendum to Application for Life Insurance
Application for One Life
Disclosure Military Sales Practice
HIPAA Authorization – Generic & CA
HIV Consent – CA
Personal Financial Supplement – CA
Supplement to Save Age – Standard