Source: http://www.quikforms.com/FormCompanies/MassMutual---Life-Forms-94
Timestamp: 2018-07-19 15:30:45
Document Index: 145073242

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HIV Consent - DE
If Insured is Delaware Resident Lit No: N201DE
Revised: 05/01/2007 Form ID: 2760
Publish: 10/29/2005 Details
Not for Pension Plan owned policies Lit No: F5159
Revised: 01/01/2013 Form ID: 6008
Publish: 05/23/2013 Details
Definition Of Replacement - NY
This form must be completed for all New York sales Lit No: F6484
Revised: 08/21/2015 Form ID: 6129
Publish: 09/24/2015 Details
Ins Dept of the State of NY Disclosure Statement
Important Notice to Applicant for Life Insurance or an Annuity - Replacement Form. This form is required for all NY replacements Lit No: F5436NY
Revised: 08/01/2015 Form ID: 6142
Important Notice to Applicant for Life Insurance or an Annuity - Replacement Form. This form is required for all NY replacements Lit No: F5436NY(L)
Revised: 08/01/2015 Form ID: 6164
Important Notice to Applicant for Life Insurance o
- Replacement Form. Lit No: F5436MA
Revised: 08/01/2007 Form ID: 6165
Publish: 10/12/2007 Details
Lit No: F5436WA
Revised: 08/01/2011 Form ID: 6167
Publish: 09/08/2011 Details
- Replacement Form. Lit No: F5436CA
Revised: 09/01/2009 Form ID: 6169
Publish: 11/03/2017 Details
Lit No: F5436DE
Revised: 08/01/2007 Form ID: 6170
Lit No: F5436FL
Revised: 08/01/2007 Form ID: 6171
Lit No: F5436GA
Revised: 08/01/2007 Form ID: 6172
Lit No: F5436ID
Revised: 08/01/2007 Form ID: 6173
Lit No: F5436IL
Revised: 08/01/2007 Form ID: 6174
Lit No: F5436IN
Revised: 08/01/2007 Form ID: 6175
Replacement Form for Kansas. Lit No: F5436KS
Revised: 03/01/2010 Form ID: 6176
Publish: 07/16/2012 Details
Lit No: F5436MN
Revised: 08/01/2007 Form ID: 6177
Lit No: F5436MO
Revised: 08/01/2007 Form ID: 6178
Lit No: F5436NE
Revised: 08/01/2007 Form ID: 6179
Lit No: F5436NV
Revised: 08/01/2007 Form ID: 6180
Lit No: F5436OK
Revised: 08/01/2007 Form ID: 6182
Lit No: F5436PA
Revised: 08/01/2007 Form ID: 6183
Lit No: F5436PR
Revised: 08/01/2007 Form ID: 6184
Lit No: F5436MI
Revised: 08/01/2007 Form ID: 6187
Lit No: F5436TN
Revised: 08/01/2007 Form ID: 6189
Important Replacement Notice to Applicant for Life
Lit No: F5436WY
Revised: 07/18/2014 Form ID: 6193
New York Authorization for Disclosure of Informati
Authorization for Disclosure of Information - This form must be submitted with the proper Disclosure Statement. (Annuity to Annuity - F5436NY(A) or Life to Annuity - F5436NY(L) Lit No: F6512
Revised: 08/21/2015 Form ID: 6194
Use this form for all cash surrenders. PLEASE NOTE: this form may NOT be used to surrender an Annuity Contract however, it may be used for an internal exchange of a MassMutual life policy to a MassMut Lit No: f6309
Revised: 06/26/2018 Form ID: 6195
Simplified Underwriting Supplement to Application
For use with HECV, 10PL, LPL65. Use with Simplified Underwriting and Non-Qualified elections only in conjunction with F4945. Lit No: A60SGE604
Revised: 12/09/2004 Form ID: 6198
MMLISI Disclosure Brochure - Connecting You With t
This disclosure brochure must be delivered to all clients no later than at the time the client signs the Investor Account Form or the NFS Brokerage Account Application. The brochure must also be deli Lit No: MI1054
Revised: 03/17/2010 Form ID: 6394
Publish: 06/08/2010 Details
or Annuities Lit No: F6487
Revised: 07/18/2014 Form ID: 6915
Modified Endowment Contract Notice and Acknowledge
Use this form for MEC contract changes. Includes the MEC Client Guide, "Your Policy and Your Taxes". This form is fillable online. Type the requested information, print, obtain all required signatures Lit No: A5030
Revised: 01/01/2011 Form ID: 6916
Premium Allocation Request Variable Life Product
Use this form for SVUL / VUL Allocation initial set-up and changes. Replaces the F5230. Lit No: F6464
Revised: 05/01/2018 Form ID: 6917
Publish: 05/07/2018 Details
Variable Life Product Directed Monthly Deduction P
Program Request. Use this form to elect to have monthly policy charges deducted from the account value in one investment option, rather than from all options on a pro rata basis. This form is fillable Lit No: F9555
Revised: 05/01/2018 Form ID: 6921
Publish: 04/27/2018 Details
Variable Life Product Portfolio Rebalancing Reques
For automated, periodic transfers of invested monies among the specified divisions of the separate account. This form is now fillable online. Type in the requested information, print the form, obt Lit No: F9510
Revised: 05/01/2018 Form ID: 6923
VUL Guard / SVUL Guard Dollar Cost Averaging Reque
Reuest. Use this form to initiate or update Dollar Cost Averaging for VUL/SVUL Guard policies. Lit No: F7821
Revised: 05/01/2018 Form ID: 6925
VUL Guard Partial Withdrawal Request
Use this form for VUL Guard withdrawals. This form is fillable online. Type in the requested information, print the form, obtain all required signatures and submit for processing. Lit No: f4943
Revised: 06/26/2018 Form ID: 6929
Service Request (Keogh [H.R. 10] Plan Policies Onl
Multi-service form for dividend withdrawals, election of reduced paid-up or extended term insurance, and election or cancellation of the Automatic Premium Loan (APL) provision for Keogh Plan policies. Lit No: f5341K
Revised: 06/26/2018 Form ID: 6931
Attending Physician`s Psychiatric Questionnaire
Attending Physician's Psychiatric Questionnaire Lit No: M1488
Revised: 04/01/2007 Form ID: 6935
Important Notice: Replacement of Life Insurance or
Required in Utah only Lit No: F6487UT
Revised: 08/01/2009 Form ID: 6936
Partial Standing Dividend Order, Modified WL Polic
Use this form for SDO on Mod 5 WL policies beginning in the 6th policy year. Partial SDO allows use of dividends to pay the difference between the initial and the ultimate premium. This form is fillab Lit No: F6488
Revised: 12/09/2010 Form ID: 6951
Publish: 01/03/2010 Details
Use this form for Ownership/Beneficiary Changes - One Sum. This form designates the owner as the beneficiary (unless the owner is the Insured and then the Estate of the Insured is the beneficiary.) If Lit No: F5248E
Revised: 09/01/2010 Form ID: 8094
Publish: 03/15/2011 Details
Loan Repayment Authorization
Use this form to set-up automatic bank drafts to repay loans. Replaces the F5273 and R1405. Lit No: F6597
Revised: 05/02/2010 Form ID: 8095
Publish: 03/17/2006 Details
Policy Change Application Part 1 - Kansas
Use this form for all policy changes requiring evidence of insurability in KS, e.g. smoker changes, UL/VL increases, rider changes, face amount changes. When exercising the Guaranteed Insurability Rid Lit No: A11KS
Revised: 07/06/2018 Form ID: 8096
Policy Change Application Part 1 - Arkansas
Use this form for all policy changes requiring evidence of insurability in AR, e.g. smoker changes, UL/VL increases, rider changes, face amount changes. When exercising the Guaranteed Insurability Rid Lit No: A11AR
Revised: 07/06/2018 Form ID: 8097
Policy Change Application Part 1 - California
Use this form for all policy changes requiring evidence of insurability in CA, e.g. smoker changes, UL/VL increases, rider changes, face amount changes. When exercising the Guaranteed Insurability Rid Lit No: A11CA
Revised: 07/06/2018 Form ID: 8098
Policy Change Application Part 1 - Florida
Use this form for all policy changes requiring evidence of insurability in FL, e.g. smoker changes, UL/VL increases, rider changes, face amount changes. When exercising the Guaranteed Insurability Rid Lit No: A11FL
Revised: 07/06/2018 Form ID: 8099
Policy Change Application Part 1 - Indiana
Use this form for all policy changes requiring evidence of insurability in IN, e.g. smoker changes, UL/VL increases, rider changes, face amount changes. When exercising the Guaranteed Insurability Rid Lit No: A11IN
Revised: 07/06/2018 Form ID: 8101
Policy Change Application Part 1 - Kentucky
Use this form for all policy changes requiring evidence of insurability in KY, e.g. smoker changes, UL/VL increases, rider changes, face amount changes. When exercising the Guaranteed Insurability Rid Lit No: A11KY
Revised: 07/06/2018 Form ID: 8102
Policy Change Application Part 1 - Maine
Use this form for all policy changes requiring evidence of insurability in ME, e.g. smoker changes, UL/VL increases, rider changes, face amount changes. When exercising the Guaranteed Insurability Rid Lit No: A11ME
Revised: 07/06/2018 Form ID: 8103
Policy Change Application Part 1 - Maryland
Use this package for all policy changes after 90 days that require evidence of insurability for contracts issued in Maryland, e.g. smoker changes, UL/VL increases, rider attachments, and face amount A Lit No: A11MD
Revised: 07/06/2018 Form ID: 8104
Policy Change Application Part 1 - Massachusetts
Use this form for all policy changes requiring evidence of insurability in MA, e.g. smoker changes, UL/VL increases, rider changes, face amount changes. When exercising the Guaranteed Insurability Rid Lit No: A11MA
Revised: 07/06/2018 Form ID: 8105
Policy Change Application Part 1 - Minnesota
Use this form for all policy changes requiring evidence of insurability in MN, e.g. smoker changes, UL/VL increases, rider changes, face amount changes. When exercising the Guaranteed Insurability Rid Lit No: A11MN
Revised: 07/06/2018 Form ID: 8106
Policy Change Application Part 1 - Missouri
"Use this package for all policy changes after 90 days that require evidence of insurability for contracts issued in MIssouri, e.g. smoker changes, UL/VL increases, rider attachments, and face amount Lit No: A11MO
Revised: 07/06/2018 Form ID: 8107
Policy Change Application Part 1 - New Jersey
Use this package for all policy changes after 90 days that require evidence of insurability for contracts issued in New Jersey, e.g. smoker changes, UL/VL increases, rider attachments, and face amount Lit No: A11NJ
Revised: 07/06/2018 Form ID: 8108
Policy Change Application Part 1 - New Mexico
Use this form for all policy changes requiring evidence of insurability in NM, e.g. smoker changes, UL/VL increases, rider changes, face amount changes. When exercising the Guaranteed Insurability Rid Lit No: A11NM
Revised: 07/06/2018 Form ID: 8109
Policy Change Application Part 1 - New York
Use this form for all policy changes requiring evidence of insurability in NY e.g. smoker changes, UL/VL increases, rider changes, face amount changes. When exercising the Guaranteed Insurability Ride Lit No: A11NY
Revised: 07/06/2018 Form ID: 8110
Policy Change Application Part 1 - North Carolina
Use this form for all policy changes requiring evidence of insurability in NC, e.g. smoker changes, UL/VL increases, rider changes, face amount changes. When exercising the Guaranteed Insurability Rid Lit No: A11NC
Revised: 07/06/2018 Form ID: 8111
Policy Change Application Part 1 - Ohio
Use this form for all policy changes requiring evidence of insurability in OH, e.g. smoker changes, UL/VL increases, rider changes, face amount changes. When exercising the Guaranteed Insurability Rid Lit No: A11OH
Revised: 07/06/2018 Form ID: 8112
Policy Change Application Part 1 - Oklahoma
Use this form for all policy changes requiring evidence of insurability in OK, e.g. smoker changes, UL/VL increases, rider changes, face amount changes. When exercising the Guaranteed Insurability Rid Lit No: A11OK
Revised: 07/06/2018 Form ID: 8113
Policy Change Application Part 1 - Oregon
Use this form for all policy changes requiring evidence of insurability in OR, e.g. smoker changes, UL/VL increases, rider changes, face amount changes. When exercising the Guaranteed Insurability Rid Lit No: A11OR
Revised: 07/06/2018 Form ID: 8114
Policy Change Application Part 1 - Pennsylvania
Use this package for all policy changes after 90 days that require evidence of insurability for contracts issued in Pennsylvania, e.g. smoker changes, UL/VL increases, rider attachments, and face amou Lit No: A11PA
Revised: 07/06/2018 Form ID: 8115
Policy Change Application Part 1 - Puerto Rico
"Use this package for all policy changes after 90 days that require evidence of insurability for contracts issued in Kansas, e.g. smoker changes, UL/VL increases, rider attachments, and face amount in Lit No: A11PR
Revised: 07/06/2018 Form ID: 8116
Policy Change Application Part 1 - South Carolina
Use this form for all policy changes requiring evidence of insurability in SC, e.g. smoker changes, UL/VL increases, rider changes, face amount changes. When exercising the Guaranteed Insurability Rid Lit No: A11SC
Revised: 07/06/2018 Form ID: 8117
Policy Change Application Part 1 - Texas
Use this form for all policy changes requiring evidence of insurability in TX, e.g. smoker changes, UL/VL increases, rider changes, face amount changes. When exercising the Guaranteed Insurability Rid Lit No: A11TX
Revised: 07/06/2018 Form ID: 8118
Policy Change Application Part 1 - VT
Use this form for all policy changes requiring evidence of insurability in AR, e.g. smoker changes, UL/VL increases, rider changes, face amount changes. When exercising the Guaranteed Insurability Rid Lit No: A11VT
Revised: 07/01/2018 Form ID: 8119
Policy Change Application Part 1 - VA
Use this form for all policy changes requiring evidence of insurability in AR, e.g. smoker changes, UL/VL increases, rider changes, face amount changes. When exercising the Guaranteed Insurability Rid Lit No: A11VA
Revised: 07/01/2018 Form ID: 8120
Policy Change Application Part 1 - Washington
Use this form for all policy changes requiring evidence of insurability in WA, e.g. smoker changes, UL/VL increases, rider changes, face amount changes. When exercising the Guaranteed Insurability Ri Lit No: A11WA
Revised: 07/06/2018 Form ID: 8121
Policy Change Application Part 1 - WI
Use this form for all policy changes requiring evidence of insurability in AR, e.g. smoker changes, UL/VL increases, rider changes, face amount changes. When exercising the Guaranteed Insurability Rid Lit No: A11WI
Revised: 07/01/2018 Form ID: 8122
Policy Change Application Part 1 - WY
Use this form for all policy changes requiring evidence of insurability in AR, e.g. smoker changes, UL/VL increases, rider changes, face amount changes. When exercising the Guaranteed Insurability Rid Lit No: A11WY
Revised: 07/01/2018 Form ID: 8123
UL Guard / SUL Guard Premium Allocation / Transfer
Use this form to change the death benefit option from DBO 1 to DBO 4. May also be used to elect initial premium allocations, change current premium allocations and transfer values between accounts for Lit No: F7839
Revised: 12/01/2005 Form ID: 8124
F6112 - MMLISI Replacement / Change Form
Use this form for any transaction which involves a change from one mutual fund family, variable annuity, variable life product, or Section 529 plan to another. (MF VA VL 529 Change Form.) Lit No: F6112
Revised: 05/02/2008 Form ID: 8383
Publish: 05/20/2008 Details
Noncitizen and/or Foreign Travel and Residence Sup
Provides detail regarding the proposed insured's citizenship status, foreign travel plans or residence. (FL Version) Lit No: F6290FL
Revised: 11/01/2012 Form ID: 8522
Life/Disability Concurrent Cover Sheet
Enclose this form with each Life and DI concurrent application package. Include the policy number for both the Life and DI policies on this sheet. Concurrent applications (Life/DI) and subsequent requ Lit No: F6701
Revised: 05/01/2000 Form ID: 8546
Life Reinstatement Application Package - Florida
Use this package for reinstatement of all life policies issued in Florida, including traditional life and term, UL, and VL. This package contains the following forms: Application for Reinstatement (A4 Lit No: A4531FL
Revised: 06/24/2017 Form ID: 8549
Publish: 09/15/2017 Details
Qualified Plan Illustration Receipt Acknowledgemen
Qualified Plan Illustration Receipt Acknowledgement and Signature page for multiple policies. A Certification F5502 form signed by the producer and applicant may be submitted with a Qualified Plan App Lit No: F5502
Revised: 11/01/2010 Form ID: 8806
Publish: 11/08/2010 Details
UL Guard / SUL Guard Guaranteed Death Benefit Elec
Lit No: F7001
Revised: 04/06/2009 Form ID: 8807
Maryland Disclosure Statement
For VUL Guard, SVUL Guard, UL Guard, and SUL Guard in Maryland Lit No: N220-MD-503
Revised: 05/01/2003 Form ID: 8836
Limited Guarantee Against Termination - Massachuse
The N220-MA-1205 is required with UL Guard and SUL Guard products in Massachusetts. Lit No: N220-MA-1205
Revised: 03/17/2006 Form ID: 8861
Standing Dividend Order (SDO)
Use this form to establish a Standing Dividend Order (SDO) on a qualifying MassMutual-issued policy using that policy`s dividends to pay its own premiums or to use dividends from another MassMutual po Lit No: F5252
Revised: 12/09/2010 Form ID: 8862
Coverage and Premium Payment Information
Coverage and Premium Payment Information - Detach and leave with client. Lit No: COR4628
Revised: 04/01/2006 Form ID: 9210
Premium Finance Supplement, Disclosure &amp Ack
The F7002 should be completed when Producer Statement (A1AGE 107) Question 7 is answered "Yes". Lit No: F7002
Revised: 03/31/2015 Form ID: 9212
To be completed by the soliciting Producer for all Life Insurance applications. Lit No: a1age
Revised: 07/06/2018 Form ID: 9388
HIPAA Authorization - CW
Lit No: F8186
Revised: 03/01/2014 Form ID: 9398
Publish: 07/24/2014 Details
HIPAA Authorization Psychotherapy Notes - CW
Lit No: F8187
Revised: 03/01/2014 Form ID: 9399
Important Privacy and Consumer Information
Important Privacy and Consumer Notification Lit No: N2000
Revised: 05/01/2015 Form ID: 9400
Publish: 01/21/2009 Details
Conversion Account Deposit Transaction
Use this form to send a client's check to be deposited into the Conversion Account. Lit No: F5458
Revised: 03/20/2009 Form ID: 9410
Publish: 04/02/2009 Details
Conversion Account Transaction Order Withdrawal
Use this form to withdraw money held in a Conversion Account Lit No: F5476
Revised: 06/20/2009 Form ID: 9411
Publish: 07/13/2009 Details
Request for Dividend Option Change
Use this form for all Dividend Option changes on policies issued by MassMutual. Use the F6367 for policies issued by CM Life. Lit No: f6612
Revised: 06/26/2018 Form ID: 10008
Acknowledgement and Consent to Employer-Owned Life
This form is required when an employer is the owner of the policy or has a beneficial interest in the policy. Lit No: F7004MA
Revised: 05/18/2007 Form ID: 10194
Assignment to Effect Section 1035(a) Exchange
Use this form to initiate 1035 exchange proceedings when an external company is involved with the exchange. Also includes the LI7709, an informational guide that provides an overview of the 1035 excha Lit No: P4051
Revised: 07/18/2014 Form ID: 10551
Use this form on Trust Owned/assigned policies when the trustee is changing, either due to death or resignation. The form can be used for all products that allow a trust to be owner or assignee. The Lit No: F9561
Revised: 11/06/2006 Form ID: 10608
Publish: 12/11/2006 Details
Lit No: F5299
Revised: 10/24/2006 Form ID: 10615
Publish: 10/26/2006 Details
Application Part 2 (A50CA) - California Version
Adult Form - used for California contracts only. Lit No: A50CA197
Revised: 01/01/2006 Form ID: 10966
Publish: 01/05/2007 Details
Application Part 2 - Florida
Part 2 - used for Florida contracts only. Lit No: A50FL
Revised: 01/31/2014 Form ID: 10967
Publish: 03/07/2014 Details
Application Part 2 (A50GE) - General Version
Adult form - used for Puerto Rico contracts only. Lit No: A50GE197
Revised: 01/01/2006 Form ID: 10984
Publish: 12/18/2006 Details
Application Part 2 - General Version
Part 2 application for AK, AL, AR, AZ, CO, CT, DE, DC, GA, HI, IA, ID, IL, IN, KS, MA, MS, MT, NE, NV, NH, NC, ND, OH, RI, SD, UT, VA, WA, WV, WY Lit No: A50GE
Revised: 07/01/2004 Form ID: 10985
Application Part 2 - Kentucky version
Part 2 - used for Kentucky contracts only Lit No: A50KY
Revised: 07/01/2004 Form ID: 10986
Application Part 2 - Louisiana version
Part 2 - used for Louisiana contracts only. Lit No: A50LA
Revised: 07/01/2004 Form ID: 10987
Application Part 2 (A50MD) - Maryland Version
Adult Form, used for Maryland contracts only. Lit No: A50MD197
Revised: 01/01/2006 Form ID: 11003
Annuity Claim Packet
Use this Claim Packet to apply for death benefit proceeds under any Annuity contract. Lit No: FR1024-AN
Revised: 04/01/2018 Form ID: 11141
Life Reinstatement Application Package - Washingto
Use this package for reinstatement of all life policies issued in Washington, including traditional life and term, UL, and VL. This package contains the following forms: Application for Reinstatement Lit No: A4531WA
Revised: 06/24/2017 Form ID: 11210
Guaranty Association Notice - MN
Minnesota Guarantee Association Notice form - Outlines policyholder rights in the state of Minnesota under the Minnesota Life and Health Insurance Guaranty Association Law. Lit No: MNGA-1206
Revised: 01/08/2007 Form ID: 11211
Publish: 01/18/2007 Details
Request for APS from MassMutual
Request for APS from MassMutual - Be sure to include a copy of the authorization when submitting this form. Lit No: APSORD2
Revised: 12/01/2006 Form ID: 11279
Provides detail regarding the proposed insured`s citizenship status, foreign travel plans or residence. This Document Replaces F257. Lit No: F6290
Revised: 11/01/2012 Form ID: 11361
Publish: 06/13/2013 Details
Disability Policy Cancellation Request
Use this form to cancel a DI policy Lit No: F6365
Revised: 04/01/2017 Form ID: 11399
HIV Consent Form - Iowa
HIV Consent form Iowa version Lit No: N201IA
Revised: 10/01/2016 Form ID: 11511
Publish: 10/14/2016 Details
Oppenheimer Automatic Premium Payment Plan
Use this form to place a policy on automatic premium payments from the client's Oppenheimer accounts. Effective for all Life products. Lit No: F5472
Revised: 01/01/2017 Form ID: 12871
Publish: 01/10/2017 Details
Alcohol/Drug Questionnaire - New York version
Requested by the Underwriter when proposed insured has admitted to having a drug or alcohol abuse problem on the medical history or in the telephone or written inspection. This form provides additiona Lit No: F6008NY
Revised: 04/02/2008 Form ID: 12914
Publish: 04/10/2007 Details
Certification of Trust Agreement - for Life Insura
Required when trust to be named as policy owner or beneficiary. Trust agreements are no longer accepted (NY version - all other state contracts require the use of F6734 form). Lit No: F6734NY
Revised: 12/11/2017 Form ID: 12916
Publish: 12/18/2017 Details
Designation of Second Addressee for Grace - FL
Termination Notification Lit No: N2001FL
Revised: 08/01/2010 Form ID: 12917
Publish: 08/30/2010 Details
NAIC Requirements - PA
NAIC Requirements - PA Packet - Contains the the F6262 Certification of Disclosure Statement Delivery, the F291 PA Disclosure Statement, the F291b PA Disclosure Statement, and coversheet with instruct Lit No: F7009PA
Revised: 11/01/2010 Form ID: 12918
Publish: 11/18/2010 Details
Premium Finance Supplement, Disclosure & Acknow
The F7002NY should be completed when Producer Statement (A1AGE 107) Question 7 is answered "Yes". Lit No: F7002NY
Revised: 03/31/2015 Form ID: 12919
Temporary Life Insurance Receipt - Alabama version
Lit No: R20AL
Revised: 07/30/2009 Form ID: 12920
Publish: 07/08/2011 Details
Temporary Life Insurance Receipt - CA
Lit No: R10CA
Revised: 04/02/2007 Form ID: 12954
Publish: 04/11/2007 Details
Provides detail regarding the proposed insured's citizenship status, foreign travel plans or residence. (NY Version) Lit No: F6290NY
Revised: 04/19/2013 Form ID: 13110
Publish: 05/15/2013 Details
Variable Life Product Dollar Cost Averaging Reques
For automated, periodic transfers of invested monies from one division of the separate account to one or more other divisions and/or the Guaranteed Principal Account. This form is now fillable online. Lit No: F5286
Revised: 05/01/2018 Form ID: 13239
VULGuard /SVUL Guard Portfolio Rebalancing Request
Use this form to rebalance existing funds in the VUL/SVUL Guard fund Divisions. Lit No: F7820
Revised: 05/01/2018 Form ID: 13240
HIV Consent - MI
If Insured is Michigan Resident Lit No: N201MI
Revised: 05/04/2007 Form ID: 13378
Publish: 05/21/2007 Details
This form is required when an employer is the owner of the policy or has a beneficial interest in the policy. Lit No: F7004
Revised: 08/13/2009 Form ID: 13420
Diabetes, Glycosuria Questionnaire
Provides additional detail on the diagnosis and treatment the proposed insured undergoes to control the diabetes. Lit No: A1728
Revised: 11/01/2010 Form ID: 13515
HIV Consent Form - Wisconsin
If Insured is Wisconsin Resident Lit No: N201WI
Revised: 06/04/2007 Form ID: 13518
Required in Hawaii only Lit No: F6487HI
Revised: 08/01/2009 Form ID: 13595
Lit No: A3320-8900
Revised: 01/01/1900 Form ID: 13601
Publish: 06/20/2007 Details
Required in North Carolina only Lit No: F6487NC
Revised: 08/01/2009 Form ID: 13616
Life Insurance Application Package - Connecticut (
Use this package for LifeBridge. Contains Part 1 (A60CT1106), Producer?s Statement (A1AGE 107), State Disclosure Authorization (A1894-8900), HIPAA/Personal Health-Related Information (F8186 LIFE/DI), Lit No: LNB-CT/LB
Revised: 04/19/2013 Form ID: 13816
Publish: 05/13/2013 Details
Request for Taxpayer Identification and Certificat
IRS W-9 Taxpayer Identification form. Lit No: W-9
Revised: 11/01/2017 Form ID: 13902
Publish: 01/19/2018 Details
Temporary Life Insurance Receipt - IL
Lit No: R20IL310
Revised: 03/01/2010 Form ID: 13980
Publish: 04/12/2010 Details
Policy Loan Transfer Request Form
Available only for: Legacy Series Whole Life Products Universal Life Navigator (ULNAV) Variable Universal Life III (VUL3) Not for use with Qualified Plan or Keogh (H.R.10) Plan owned policies Lit No: F7010
Revised: 07/23/2007 Form ID: 14042
Adult Supplement to Part 2 of Application
- For health history that does not fit in Part 2 Lit No: A51GE197
Revised: 11/01/2003 Form ID: 14415
Publish: 09/18/2007 Details
To be presented to and signed by the policy owner and producer at or before the time of application Lit No: f7011
Revised: 04/01/2012 Form ID: 14681
Publish: 10/09/2007 Details
Accelerated Benefit Rider - Connecticut
To be presented to and signed by the policy owner and producer at or before the time of application Lit No: f7011ct
Revised: 06/01/2015 Form ID: 14682
Publish: 11/18/2015 Details
Accelerated Benefit Rider - Illinois
To be presented to and signed by the policy owner and producer at or before the time of application Lit No: f7011il
Revised: 06/01/2015 Form ID: 14683
Accelerated Benefit Rider - Michigan
To be presented to and signed by the policy owner and producer at or before the time of application Lit No: f7011mi
Revised: 06/01/2015 Form ID: 14685
Accelerated Benefit Rider - Mississippi
To be presented to and signed by the policy owner and producer at or before the time of application Lit No: f7011ms
Revised: 06/01/2015 Form ID: 14686