Physicians Mutual Insurance Company Annuitization Request Form

Physicians Life Insurance Company
Annuity Customer Service
PO Box 2316
Omaha, NE 68172-4081
1.800.720.2891
Annuitization Request
for Annuity Contracts
Please mark the appropriate box for each option you are requesting. Please print the requested information. All annuitization proceeds will
be mailed to the Annuitant’s address of record.
Note: If the Owner is not an individual, additional documentation as to who can sign on behalf of the Owner may be required.
Owner/Annuitant Information
Owner’s Name
Joint Owner’s Name (If applicable)
Contract Number
Fax Number (
Phone Number (
)
)
Email Address
Annuitant’s Name (If different from Owner)
Joint Annuitant’s Name (If applicable)
Distribution Options
I request to distribute the value of the above contract, less any applicable premium tax, under the following annuity income option:
Option One: Life Only
I understand Physicians Life will make payments during the life of the above-referenced Annuitant. I understand and agree payments will
cease immediately upon death of the Annuitant and the contract will terminate without further value.
Option Two: Life with Guaranteed Period of __________ years
(Minimum number of years varies by product; refer to your contract for details.)
I understand Physicians Life will make payments for the guaranteed period I have chosen and thereafter for the life of the above-referenced
Annuitant. I understand and agree upon the death of the Annuitant, any amount remaining under the guaranteed period selected will be
distributed to the Beneficiary named.
Option Three: Income for a Fixed Period of __________ years
(Minimum number of years varies by product; refer to your contract for details.)
I understand Physicians Life will make payments for the fixed period I have chosen. If the Annuitant dies during this period, payments will be
made for the remainder of the period to the Beneficiary named.
Option Four: Joint and __________% Survivor Life Income
I understand Physicians Life will make payments during the joint lifetimes of the above-referenced two Annuitants and thereafter during the
lifetime of a survivor. I understand and agree the contract ceases without value after the death of both Annuitants.
Lost Contract
I, the undersigned, certify the original contract specified above has been lost, stolen or destroyed. Said contract has not been pledged or
assigned. I am the unconditional Owner thereof, and to the best of my knowledge and belief, the original is not being held in the possession
of any other person. If at any time the original is found, I will immediately return it to the Company.
Tax Withholding
The Owner is responsible for any tax implications related to these distributions.
Please complete and return form W-4P to elect appropriate Federal Tax Withholding. Your distribution may also be subject to state tax
withholding requirements. State withholding requests can be written in on the same form. Your request will not be processed until we
receive the Annuitization Request for Annuity Contracts form as well as the completed W-4P form.
Your tax withholding election will remain in effect and apply to all future annuity payments you receive under this contract until you change or
revoke it. You may change your withholding election at any time and as often as you wish with regard to future payments in this series by
contacting us at 1-800-720-2891 or online at PhysiciansMutual.com to request a new withholding election form.
PMA2856
Rev. 0310
Annuitant Information (To be completed by Annuitant)
Annuitant’s Name
Annuitant’s Date of Birth (Attach copy of Birth Certificate or Driver's License)
/
Month
Social Security Number
―
/
Day
Year
―
Joint Annuitant’s Name
Joint Annuitant’s Date of Birth (Attach copy of Birth Certificate or Driver's License)
Social Security Number
―
/
Month
―
/
Day
Year
Annuitant Payment Mode
Please make my payments in
Monthly
Quarterly
Semiannual
Annual installments. (It will take approximately 30 days
to receive your first annuitization payment after your request has been received at Physicians Life.)
Payment deferral is available up to 12 months. If the statement below is not completed, payments will be effective when the completed
Annuitization Request for Annuity Contracts form is received. Deferral is unavailable for Death Claim payouts.
Please defer my payments __________ months.
Annuitant Beneficiary Designation
Primary Beneficiary
Name (Last, First, MI)
Address
Age
Relationship
Social Security Number/
Tax Identification Number
%
Allocation
Contingent Beneficiary - If there is no Primary Beneficiary living to receive payment, proceeds will be paid to the Contingent Beneficiary.
Name (Last, First, MI)
Address
Age
Relationship
Social Security Number/
Tax Identification Number
%
Allocation
Signatures
It is agreed and understood that:
1. With the election of this distribution option, partial withdrawals and full surrenders are not permitted;
2. The election of this distribution option is IRREVOCABLE;
3. The Owner of the contract is responsible for any taxes resulting from the payout.
X
Owner’s Signature
Date
X
Joint Owner’s Signature (If applicable)
Date
X
Annuitant’s Signature (If different from Owner)
Date
X
Joint Annuitant’s Signature (If applicable)
Date
X
Agent’s Signature (If applicable)
Date
This request will not become effective until approved by the Company in accordance with the terms of the contract. A payment certificate will
be sent when the first payment is issued.
PMA2856
Rev. 0310