In certain situations, an applicant for life insurance may have special needs that require the completion of one or more additional forms. Although most applicants will not require any of these forms, they are provided below for the convenience of those who may need them.
Additional Forms
- UN1117 - 1035a Exchange of Life Insurance/Annuity Policy - Complete this form if you intend to cancel anexisting policy and transfer the cash surrender value from the old policy to the one for which you are applying. Valid exchanges are from a life policy to a life policy, a life policy to an annuity, or an annuity to an annuity.
- UI 120 Loan Assumption - This form can be used as part of the Exchange Under Section 1035 of The Internal Revenue Code
- MD 126 - Limited Power of Attorney Appointment - Complete this form if the policy will have multiple owners or will be owned by a trust with multiple trustees.
- PS3000T - PIN Authorization and E-Delivery Election Form - Complete this form to establish a personal identification number (PIN) which you will need to have on-line access to policy values.
- UN2178- Electronic Funds Transfer Form
- UI2135 - Confidential Financial Statement - Complete this form if you are applying for $1 million or more in death benefit.
- PA163 - Transfer/Rollover Request CD/Mutual Fund Redemption Form
- AIC 472 - Client Disclosure Booklet (Fee Advisor or Client Only)
- AIC 569 - Client Receipt and Acknowledgement Form (Fee Advisor or Client Only)
- UN 1166 - Employer Owned Life Insurance Notice & Consent with IRS 8925 form
- AS1002 - Ameritas Advisor VUL
- PF423 - No Load Variable Annuity
- PF425 - Advisor Select No-Load Variable Annuity
- PF275 - Low Load Variable Universal Life
- PF274 - Low Load Variable Annuity
- PF273 - Survivorship Variable Universal Life
Policy Service Forms
- UN 3379 A Policyowner's Change and Service Request - Legal/Title Changes - Beneficiary/Ownership/Successor Ownership/Name Change/Lost Policy Affadavit/Release of Interest.
- UN 3379 B Policyowner's Change and Service Request - Dividend Election Change - Address Change/Dividend Election/Planned Periodic Premium/Duplicate Policy.
- UN 518 T Absolute Assignment and Change of Beneficiary - Irrevocable
- UN 733 B - Change of Address Form
- UN 2324 - Agreement of Designation of Beneficiary and Method of Settlement
- UN 3375 - Notice to Suspend Billing on UL/VUL Policies
- PS2313 - Third Party Transfer Authorization - Authorizes a third party to change allocation of premium payments and to transfer funds among subaccounts.
- PS231 - Interested Third Party Form - Authorization agreement to release policy information to a designated party.
- AG5216 GLWB Change & Withdrawal Request Form
- UN5238 - Annuity Withdrawal or Surrender Request Form
- UN5238SH1 Safe Harbor Explanation - required for Governmental 457 plans
- UN5238SH2 - Safe Harbor Explanation - required for 401(a), 403(a), or 403(b) plans
- AS1000 - Ameritas Advisor VUL
- PF424 - NLVA
- PF389 - LLVA
- LL-VUL/OP
- LL-SVUL/OP
- UN3899 Model Asset Allocation - When completing this form, please also review ADV Part II (see below)
- MSTAR ADV - Morningstar Asset Allocation Program ADV - ADV Part II Uniform Application for Investment Adviser Registration Form gives information about the investment adviser and its business for the use of clients. The information has not been approved or verified by any government authority.
- LAS-4AAL Aviation Questionnaire ALIC - Complete this form if you have flown within the past three years as a pilot, student pilot, crew member, had any flying duties, or if such activity is contemplated. - New York Residents See Below
- LAS-4SAL Sports Questionnaire ALIC - Complete this form if you have participated in any vehicle racing, parachuting, hang gliding, SCUBA diving or rodeos within the past 2 years. - New York Residents See Below
- LAS-4MAL Military Questionnaire ALIC - Complete this form if you are currently enlisted in the Military. - New York Residents See Below
- LAS-4DAL Diabetic Questionnaire ALIC - Complete this form if you have been diagnosed as a Diabetic. - New York Residents See Below
- UI2158 Residency & Travel Questionnaire - Complete this form if you plan to travel outside the United States in the next 12 months. Florida residents should not complete this form.
- UI2159 Alcohol Questionnaire
- UI2160 Drug Questionnaire
- LAS-4AAC Aviation Questionnaire - Complete this form if you have flown within the past three years as a pilot, student pilot, crew member, had any flying duties, or if such activity is contemplated.
- LAS-4SAC Sports Questionnaire - Complete this form if you have participated in any vehicle racing, parachuting, hang gliding, SCUBA diving or rodeos within the past 2 years.
- LAS-4MAC Military Questionnaire - Complete this form if you are currently enlisted in the Military.
- LAS-4DAC Diabetic Questionnaire - Complete this form if you have been diagnosed as a Diabetic.
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