South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:08 - Life insurance and annuities › Appendix C - Uniform Form for Life Insurance or Annuity 1035 Exchange

Current through Register Vol. 51, page 10, July 15, 2024
Uniform Transaction Form for 1035 Exchange:
Name of Insured/Annuitant:
Social Security or Taxpayer ID No:
Policy/Contract No:
Joint Insured/Annuitant
Social Security or Taxpayer ID No:
Daytime Phone No:
Policy Owner (if different than insured):
Social Security or Taxpayer ID No:
Street Address
Joint Policy Owner (if different than insured):
Social Security or Taxpayer ID No:
City, State, and Zip Code
I own the following: Life Insurance Policy Endowment Annuity Contract
The existing policy was issued by: _______________________ on _____________.
(Old Company) (Date)
The new policy is being requested for: ____________________ on _____________.
(New Company) (Date)
1035 Exchange
I (We) the undersigned owner(s) of the above named contract (existing policy), hereby assign and transfer absolutely all rights, title, and interest in the existing policy. I (We) intend this assignment to be part of a tax-free exchange under Internal Revenue Code Section 1035(a). This exchange must be on the life of the same Insured/Annuitant named in the existing policy if approved for the new policy.
I further represent:
1.
Ownership of existing policy.
I (We) am/are the sole owner(s) of the existing policy. No other person or entity has any claim or interest in or against the existing policy, except ________________________________________________.
(collateral assignees, irrevocable beneficiaries, etc.)
2.
Surrender of existing policy.
I understand and agree:
Upon approval of my application for the new policy, the new company will request the cash surrender value of my existing policy.
I know that I may take up to six months to receive the cash surrender value of my existing policy. During this time I assume full responsibility for paying any premium payments, which are now due or may become due while the surrender request is pending. I hold both old and new companies harmless from any claim if it lapses because the premiums have not been paid.
The new company will apply the case surrender value it receives from the existing policy, less any applicable short term charges. The new company will pay me any excess amounts.
I know that the payment of the cash surrender value ends all legal obligations of the old company issuing my existing policy. Thus, if the insured under this existing policy dies after the cash surrender value has been sent to the new company. I know that NO DEATH BENEFITS will be paid under the existing policy.
After the cash surrender value of my existing policy has been paid to the new policy, if I choose not to accept the new policy, the only obligation of the new company shall be to pay me the full cash surrender value received for my existing policy. I know that the company issuing the existing policy may not permit me to reinstate it after it has been surrendered.
4.
No insurance created by this form.
I understand that this form creates no insurance.
5.
Absolute assignment of existing policy.
For the purposes and with the agreements set forth above, I hereby assign, irrevocably transfer, and deliver the existing policy described above to the new company together with all right, title, and interest therein and thereto. My copy of this form when signed is my receipt for the existing policy.
6.
Acknowledgement of responsibility for tax obligations.
I understand that any tax obligations resulting from this transaction are mine and it may be in my best interest to seek professional tax advice prior to completing this transaction. I assume any and all risk with respect to accomplishment of a valid Section 1035 exchange under the Internal Revenue Code.
_________________________________ __________ _________________________________ __________
(Insured/Annuitant) (Date) (Insured/Annuitant) (Date)
_________________________________ __________ _________________________________ __________
(Policy Owner Signature) (Date) (Policy Owner Signature) (Date)
_________________________________ __________ _________________________________ __________
(Irrevocable Beneficiary or Assignee) (Date) (Collateral Assignee and Title) (Date)
_________________________________ __________ _________________________________ __________
(Witness)
(Date)
(Witness)
(Date)