Zurich Non Financial Change Form

Non-Financial Change Form Administrative Offices PO BOX 19097 Greenville SC 29602-9097 Phone number 800 449-0523 Please Print All Information Below Overnight deliveries can be sent to 2000 Wade Hampton Blvd. Section 1. Contract Owner s Information First Name M Residence Street Address Last City Home Phone Number State Zip Social Security Number Date of birth Contract Number Cell Phone Number Work Phone Number Are you a U.S. Citizen Email Address Yes No Country of residence If the answer is NO you will need to fill out a W8-BEN form and send the form to Zurich Administrative Offices PO BOX 19097 Greenville SC 29602-9097 Section 2. Non-Financial Change Form Administrative Offices PO BOX 19097 Greenville SC 29602-9097 Phone number 800 449-0523 Please Print All Information Below Overnight deliveries can be sent to 2000 Wade Hampton Blvd. Section 1. Contract Owner s Information First Name M Residence Street Address Last City Home Phone Number State Zip Social Security Number Date of birth Contract Number Cell Phone Number Work Phone Number Are you a U*S* Citizen Email Address Yes No Country of residence If the answer is NO you will need to fill out a W8-BEN form and send the form to Zurich Administrative Offices PO BOX 19097 Greenville SC 29602-9097 Section 2. Address Change Check One Owner Joint Owner Annuitant New Residence Street New Home Phone Number Contingent Annuitant Primary Beneficiary Contingent Beneficiary Temporary Permanent If you are permanently moving to another State and if you are currently receiving distributions or annuity payments Systematic Withdrawal RMD s etc please check your new State s income tax withholding rules and fill out Section 8. ZA-1025/Dec 2012 Page 1 Section 3. Name Change Print Previous Name Previous Name Signature Print New Name New Name Signature Reason for Name Change Marriage Divorce Other Please explain Other Explain Page 2 Section 4. Beneficiary Update and Change Please note that you must list all of your Primary Beneficiaries not just the ones that are new. This revised list will represent your updated selection of Primary beneficiaries. You may designate additional Primary and Contingent beneficiaries on a signed and dated separate sheet of paper. Full Name Full Address Home Phone Work Phone Cell Phone Email Relationship to Owner Allocation Percentage What do you want this Primary Beneficiary to have PLEASE MAKE SURE THAT THE SUM OF THE s FOR THE PRIMARY BENEFICIARIES TOTALS 100 The new designation cancels all previous designations subject to the rights of any existing assignment. Unless otherwise indicated the right to change the beneficiary is reserved by the owner s. If a trust is being named indicate the full name of the Contingent Beneficiaries trust and the date it was established as well as the first and last page of the trust. Percentage designations must equal 100. Such change will take effect when we receive and record it at our home office. After we receive and record the change form it will take effect on the date the change was signed* However any action taken by us before such change is received and recorded will remain valid* If not enough space is allocated for your beneficiaries please use Section 5 with all the same information from this section* Page 3 Will only be considered if all PRIMARY Beneficiaries Are No Longer Living Page 4 Section 5.