Ameritas Advisor Services

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• Quick Term Quote
• Copy of On-Line Trades
• Copy of Account Access
• Fillable Applications and Forms
• Copy of Electronic Delivery

 

 

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Need Help?

Contact our salaried professionals at 1-800-555-4655 or e-mail us at direct@ameritas.com.

For a detailed list of applications and forms needed, complete the following: Product: Term Variable Annuity Variable Life Universal Life Survivorship SVUL Survivorship UL    State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Washington D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Does applicant have existing coverage?	Yes    No
Is applicant replacing existing coverage?	Yes    No
Transfer $ from other company? (UL, VUL, VA only) 1035 Exchange   Transfer/Rollover Mutual Fund Redemption   None
Qualifed Plan? (Annuity Only)
Money Purchase Defined Benefit Roth IRA Pension/Profit Sharing Simple IRA SEP IRA TSA HR10 401(k) Traditional IRA 457 Deferred Comp.
Select riders applied for:
Child Protection Other Insured Term Payor Disability/Payor of a Monthly Deduction
Select all that apply:
Diabetic   Aviation   Hazardous Hobbies   Military   Travel   Alcohol   Drugs

 

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

• Copy of UI104 - 1035 Exchange Form - 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.
• Copy of 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.
• Copy of PS3000 - 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.
• Copy of AC203 - Automatic Bank Draft Form
• Copy of UI2135 - Confidential Financial Statement - Complete this form if you are applying for $1 million or more in death benefit.
• Copy of L5 - Application for Children's Protection Rider or Payor Disability Rider - Complete this form if you are applying for a Children's Protection Rider or if you are applying for Payor Waiver of Disability Rider.
• Copy of PA163 - Transfer/Rollover Request CD/Mutual Fund Redemption Form

Expense/Disbursement Allocation Form: Use this form to direct systematic deductions be withdrawn from a specific subaccount(s)

• Copy of PF273 - Survivorship Variable Universal Life
• Copy of PF274 - Low Load Variable Annuity
• Copy of PF275 - Low Load Variable Universal Life
• Copy of PF423 - No Load Variable Annuity
• Copy of PF425 - Genesis Variable Annuity
• Copy of PS2461LL - Variable - Legal Service Request Form - Beneficiary/Ownership/Successor Ownership/Name Change/Lost Policy Affadavit/Release of Interest.
• Copy of PS2461TRAD - Fixed - Legal Service Request Form - Beneficiary/Ownership/Successor Ownership/Name Change/Lost Policy Affadavit/Release of Interest.
• Copy of PS2461NY-TRAD - Fixed - New York Legal Service Request Form - Beneficiary/Ownership/Successor Ownership/Name Change/Lost Policy Affadavit/Release of Interest.
• Copy of PS2313 - Third Party Transfer Authorization - Authorizes a third party to change allocation of premium payments and to transfer funds among subaccounts.

Withdrawal or Surrender Request Forms

• Copy of WDREQ - IRA, Simple, Roth, SEP and Non-Qualified Plans - New York Residents See Below
• Copy of QPWDREQ - For Qualified Pension or Profit Sharing Plans Only - New York Residents See Below
• Copy of TSAWD - For TSA (Tax Sheltered Annuity) plans Only - New York Residents See Below
• Copy of 457WD - 457 Deferred Compensation Plan Only - Used to make a request for a partial, systematic or full withdrawal from existing variable policy. - New York Residents See Below
• Copy of RMD Required Minimum Distribution Form
• Copy of AG4287 Model Asset Allocation & Investment Advisory Agreement

Withdrawal or Surrender Request Forms - For Residents of New York

• Copy of WDREQ - IRA, Simple, Roth, SEP and Non-Qualified Plans - NY
• Copy of QPWDREQ - For Qualified Pension or Profit Sharing Plans Only - NY
• Copy of TSAWD - For TSA (Tax Sheltered Annuity) plans Only - NY
• Copy of 457WD - 457 Deferred Compensation Plan Only - NY - Used to make a request for a partial, systematic or full withdrawal from existing variable policy.

Systematic Programs & Optional Investment Strategies Forms - Request Dollar Cost Averaging, Portfolio Re-balancing or Earnings Sweep. Can change current and future allocations or make unscheduled deposits.

• Copy of PF389 - LLVA
• Copy of PF390 - LLVUL
• Copy of PF391 - LLSVUL
• Copy of PF424 - NLVA

Questionnaires

• Copy of 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
• Copy of 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
• Copy of LAS-4MAL Military Questionnaire ALIC - Complete this form if you are currently enlisted in the Military. - New York Residents See Below
• Copy of LAS-4DAL Diabetic Questionnaire ALIC - Complete this form if you have been diagnosed as a Diabetic. - New York Residents See Below
• Copy of UI2158 Residency & Travel Questionnaire - Complete this form if you plan to travel outside the United States in the next 12 months.
• Copy of UI2159 Alcohol Questionnaire
• Copy of UI2160 Drug Questionnaire

Questionnaires - For Residents of New York

• Copy of LAS-4AAL Aviation Questionnaire ALIC - NY - 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.
• Copy of LAS-4SAL Sports Questionnaire ALIC - NY - Complete this form if you have participated in any vehicle racing, parachuting, hang gliding, SCUBA diving or rodeos within the past 2 years.
• Copy of LAS-4MAL Military Questionnaire ALIC - NY - Complete this form if you are currently enlisted in the Military.
• Copy of LAS-4DAL Diabetic Questionnaire ALIC - NY - Complete this form if you have been diagnosed as a Diabetic.