3297_RET Policy Transfer Form.indd

Transfer of Policy Ownership Form
NOTE: To complete the transfer and ensure continuous coverage, all sections of this form must be completed.
Current and new owners should keep copies of this form for their records. The new owner must contact
Nationwide to provide payment information within seven business days of submitting this form.
Failure to do so will result in cancellation of this policy. The following plan is not eligible for policy transfer:
Pet Wellness Basics.
WHAT IS THE REASON FOR THIS REQUEST? (Name change, new owner, military relocation, etc.)
Pet’s Current Name:
If pet will be given a new name in transfer, indicate new name here:
Pet’s Breed:
(Must match current records) 3
Pet’s Date of Birth:
(Must match current records)
Current Policy Number:
(Note: when transfer is complete, the new owner will be assigned a new policy number.)
Phone Number:
E-mail Address:
I am the current policyholder and request cancellation of my policy and transfer to the new owner listed in section 4.
Print Current Policyholder Name 4
Current Policyholder Signature Date
Phone Number: (Day)
E-mail Address:
Relationship to current policyholder:
q Spouse/Domestic Partner
For your security, DO NOT include your payment information on this form. You must contact Nationwide to set up a new payment
method within seven business days. By accepting this transfer, you accept financial responsibility for the new policy.
I accept this transfer of ownership and request that Nationwide issue a new policy to me covering the pet referenced above, and
accept financial responsibility for this policy when a new policy number and effective date are issued. I understand that all terms
and conditions in the current owner’s policy will transfer to my new policy. I understand that any premium refund under the current
owner’s policy and any claim payments for claims with a date of service before this transfer will be paid to the current owner. I also
understand that I must contact Nationwide to provide my payment information within seven business days from submitting this
completed form to complete the transfer.
Print New Policyholder Name 5
New Policyholder Signature Date
Mail or fax completed form to: Nationwide, PO Box 2344, Brea, CA 92822 or fax to 714-989-0537
For more information, please contact one of our licensed agents at 1-800-874-5607, Monday–Friday
from 5:00 a.m. to 7:00 p.m. or Saturday from 7:00 a.m. to 3:30 p.m. (Pacific).