RIGHTS CHANGE FORM SAMPLE WORDINGS

USFL
PO BOX 1419
Charlotte NC 28201-1419
Phone: 800-959-3894
RIGHTS CHANGE FORM
(Page 1 of 4)
Section 1. Designation of Rightsholder (Owner)
To change the rightsholder (owner) on your policy, check the appropriate box. Complete section 1 in its entirety.
Section 2. Signatures
To sign on behalf of a corporation:
1.
An officer other than the Insured and other than the secretary must sign and the signing officer must specify his/her corporate title.
2.
I f the only two officers in the corporation are the Insured and the secretary, please submit a statement to that effect or indicate that fact in Section 4. See below for
additional signature requirements:
Professional Corporation (“PC”)
Officer or Shareholder. Prefer someone who is both
Registered Limited Liability
Partnership (“R.L.L.P.”)
Partner
Limited Liability Company (“L.L.C.”)
Member or Manager. Any other person would have to approve his/her authority under its opening agreement of Articles of Organization.
Professional Service L.L.C. (“P.S.L.L.C.”) Same as L.L.C.
3.
State the complete legal name of the Corporation as it appears in your Charter or Certificate of Incorporation. DO NOT use the corporate assumed name alone (its d/b/a).
4.
The final beneficiary and/or rightsholder (owner) will be the Corporation’s successors or assigns.
To sign for a partnership:
1.
A general partner other than the insured must sign in the following manner: (state full name of the partnership)
By:
2.
. A limited partner may not sign for a partnership.
(member name of firm)
The final beneficiary and/or rightsholder (owner) will be the Partnership’s successor or assigns.
To sign on behalf of a tax-qualified plan:
1. The Qualified trustee(s) must sign in the capacity of “trustee”, of the qualified/tax-sheltered plan, not individually.
2. State the full name of the tax-qualified plan as it appears in the plan.
SAMPLE WORDINGS
SAMPLE WORDINGS FOR COMPLETING RIGHTSHOLDER (OWNER) DESIGNATIONS IN SECTION 3b, IF APPLICABLE.
If you wish to designate . . .
SINGLE RIGHTSHOLDER
a person
corporation
partnership
TRUST RIGHTSHOLDER Usually no other
rightsholder, and no FINAL rightsholder, needs to be
named after this (an Irrevocable trust) designation; but,
if there is a need to do so, (a revocable trust) complete
the FINAL rights (Section 3B) or send us full details
and we will propose a designation for you.
Please use this language . . .
Jane Doe, spouse
XYZ Corporation, or its successors or assigns.
Smith and Jones, a partnership, or its successors or assigns.
John Jones (or XYZ Bank) as trustee or his (its) successor trustee under an Agreement dated May 1, 1978 made
by and between the Insured and said trustee.
GROUP (more than one person) RIGHTSHOLDER
Group rightsholders must act Jointly and ownership interests
cannot be apportioned.
Children
parents
Insured’s children
children, Jane Doe, John Doe and Mary Doe
children of marriage of Insured and spouse, Mary Doe
children of marriage of Insured and spouse, Mary Doe, including John Doe and
Susan Doe
Mother, Jane Doe and Father, James Doe -ORMother and Father of Insured, Jane and James Doe, respectively.
Continued on next Page
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SAMPLE WORDINGS CONTINUED
(Page 2 of 4)
SINGLE PRIMARY RIGHTSHOLDER AND SINGLE CONTINGENT RIGHTSHOLDER
spouse, followed by child
— Spouse, Mary Doe, if living, if not, daughter, Jane Doe
SINGLE PRIMARY RIGHTSHOLDER AND GROUP CONTINGENT RIGHTSHOLDER
spouse, followed by unnamed children
— Spouse, Mary Doe, if living, if not, Insured’s children
spouse, followed by named children
— Spouse, Harry Doe, if living, if not, son, Frank Doe and daughter, Jane Doe
GROUP PRIMARY RIGHTSHOLDERS AND SINGLE CONTINGENT RIGHTSHOLDER
children, followed by spouse
— Insured’s children, if none is living, spouse, Mary Doe
General Information for Change in Ownership
I f the new Owner is a U.S. citizen, they must have a primary residence in the United States. If the person is a U.S. Citizen but lives abroad, the change of ownership will
require the approval of the AXA Equitable Anti-Money Laundering Office (AMLO).
I f the new Owner is not a U.S. citizen, they must have a primary resident address in the U.S. and have an unexpired visa or Green Card. Copies of the unexpired visa or
Green Card must be submitted with this request. We will accept an unexpired visa in the following visa categories: A, E, G, H, I, K, L, N, NATO, P, R, S, T, TN, TD,
U TPS or V. We will also need a copy of an unexpired visa and 1-94 document.
Non-U.S. citizen that has a visitor’s visa, an expired Green Card or visa, no visa or has a visa in the following categories: B, C, D, F, J, M, Q, TWOV, will not be
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accepted as a new Owner and the ownership change must be declined under the AXA Financial Anti-Money Laundering policy.
•
For Legal Resident Aliens: A copy of the unexpired Green Card or acceptable visa and 1-94 form will be required to be submitted with the change of ownership request.
or Trusts: Taxpayer Identification Number of the Trust and a copy of a Trust certification or significant pages and signature page of the Trust Agreement that proves the
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existence of the Trust, the name and date of the Trust Agreement, as well as the name of the Trustee(s).
•
For Partnerships: Pertinent page from the Partnership agreement that proves the Partnership exists and indicates the names of the Partners.
•
or Private Corporations: Articles of Incorporation or copy of business license and documentation indicating the acting party has the authority to act on behalf of the
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Corporation.
For Publicly Traded Corporations: No additional requirements need to be submitted.
•
ll non-resident individual and foreign business (Corporation, Trust, Partnership) new Owners require the approval of the AXA Equitable AMLO. In addition to the
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requirements outlined above, the AMLO also requires these new Owners to have a U.S. Bank account.
General Information for New Owner(s) concerning Taxpayer Identification Number
•
Federal Law requires you to provide to us the correct Taxpayer Identification Number which matches your name.
•
If you fail to provide the correct Taxpayer Identification Number, tax withholding may be required and penalties may apply.
•
our Taxpayer Identification Number is your Social Security Number if you are an individual and a U.S. person. A U.S. person Is a U.S. citizen, or a non-citizen of
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the United States who is a U.S. resident for tax purposes. If you are a foreign individual who is not eligible to apply for a Social Security Number, your Taxpayer
Identification Number Is your Individual Taxpayer Identification Number or “ITIN” Issued by the IRS. If you are an entity (U.S. or foreign), your Taxpayer
Identification Number Is the Employer Identification Number or “EIN” issued by the IRS.
•
I n the case of a minor, the minor’s Social Security Number must be provided. If the minor does not have a Social Security Number, the natural guardian for the minor’s
owner may obtain one by applying to the Social Security Administration on Application Form SS-4. If the newly acquired number is not received by U.S. Financial Life
insurance within 60 days, U.S. Financial Life Insurance Company is required by law to withhold on any taxable interest being credited to the policy/ contract.
General Information on USA PATRIOT Act - Customer Identification Program
Section 326 of the USA PATRIOT Act outlines important information about procedures for opening new accounts
o help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record
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information that identifies each person who opens an account.
o comply with Section 326, U.S. Financial Life Insurance Company will ask for your name, address, dale of birth, and other information necessary to allow us to
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identify you when opening an account. We may also ask to see your driver’s license or other identifying documents.
You May Use This Form:
To change the rightsholder.
For any number of policies, provided you are requesting an identical change for each policy.
TAX CONSEQUENCES
An attorney should be consulted about possible tax consequences in the following instances:
(a) If the rightsholder is not the Insured and is not the beneficiary; (b) if the rightsholder designates joint rights to two or more individuals, as a gift; (c) if the rightsholder is a
corporation and is not a beneficiary; (d) if rights are changed on an annuity Issued after April 22,1987; (e) a transfer to a person two or more generations younger than the transfer
or (generation skipping); (f) If the policy has a loan and the rights are being transferred as a gift.
Please be advised: Due to IRS implementation of the Foreign Account Tax Compliance Act (FATCA), taxable disbursements made to entity (business, trust or estate) owners/
payees may be subject to 30% withholding if proper documentation is not on file. Proper documentation is considered to be a properly completed and signed IRS Form W-9 for
domestic entities. Foreign entities are expected to submit a properly completed and correct type of IRS Form W-8. In the event proper documentation is not on file with AXA US
(AXA Equitable, MLOA & USFL), we will withhold the required 30% upon disbursement. For further details regarding the FATCA rules and regulations and how disbursements
may be affected, please contact your tax advisor.
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USFL
PO BOX 1419
Charlotte NC 28201-1419
Phone: 800-959-3894
(Page 3 of 4)
RIGHTS CHANGE FORM
POLICY NUMBER
FOR OFFICE USE ONLY:
INSURED
REQUEST APPROVED:
POLICY OWNER
ON:
POLICY OWNER DATE OF BIRTH
BY:
BROKER
U.S. FINANCIAL LIFE INSURANCE CO.
1. RIGHTS
Rightsholder, Contract
Holder (Owner) on record
remains unchanged Unless
this section is completed.
Where two or more
Rightsholders are
Designated, those Living
shall act jointly unless
otherwise indicated.
IRS Form W-9 must be
completed by the NEW
RIGHTSHOLDER
AND Submitted to the
Company with new
Rightsholder’s TIN
If more than one new
owner is designated, make
a copy of page 3 and fully
complete Section 1 for
each new owner. Each
form must reference policy
number and be signed and
dated with the same date. If
adding a successor owner,
primary owner (s) must be
restated.
Is this ownership change in connection with a viatical or life settlement transaction?
o Yes
o No
Is the new owner a US citizen or a legal entity established under US law?
o Yes
o No
If the new owner is a nominee, fiduciary or intermediary for a beneficial owner,
Is the beneficial owner a US citizen or a legal entity established under US law?
o Yes
o No
Please change the Policy(ies) so that all rights provided in “Rights (Ownership) Under Policy” (refer to #5 on Page 4)
belong exclusively to (if naming joint rightsholders, the following information needs to be provided for all named rightsholders):
a.
o Insured/Annuitant o Individual o Trust o Partnership o Corporation o Other
Full name of Proposed Rightsholder(s)
Relationship to Insured / Annuitant
Date of Birth
Legal Residence (Full Street, City, State, Zip)
Mailing Address (if different from Legal Address)
New Rightsholder Occupation and Type of Business
Soc Sec #/TIN (IRS Form W-9 signed by new rightsholder must be included)
All non-resident individual and foreign business new rightsholders must have a US Bank
Account: Name of Bank
Account Number
New Rightsholder e-mail address
New Rightsholder telephone number
One box must be checked
b. FINAL RIGHTSHOLDER (IF ALLPERSONS DESIGNATED IN a. PREDECEASED THE INSURED)
o The Insured / Annuitant
o The executors and administrators of the rightsholder, if two or more rightsholders, the executors or administrators of the
survivor of said rightsholders (the last to die)
2. SIGNATURES The undersigned Rightsholder (Owner) requests the Company to accept and record the designations above, to add the provisions of this form his/her/its policy/
contract (if necessary to update it), to issue an endorsement consistent with the above designations or to accept this form as an endorsement (whichever it deems appropriate), and to
accept any material changes above that I have initialed or otherwise ratified. If signing on behalf of a corporation or partnership, see “Instructions for completing this form” page 1.
Signature of Owner
Additional Signature
First Name
Initial
Last Name
First Name
Initial
Last Name
Witness
Date
If Rightsholder (Owner) resides in Massachusetts, a witness is mandatory
and a named beneficiary may not be a witness.
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GENERAL PROVISIONS
1.DEFINITIONS
(a) “WE”, “US”, “OUR” and “Company” refer to U.S. Financial Life Insurance Co
or any of its insurance subsidiaries.
(b)HOME OFFICE. Our Processing Center is located in Charlotte, North Carolina.
Our Address is: USFL, PO BOX 1419, Charlotte NC 28201-1419
(c) RELATIONSHIPS. All relationships used in the beneficiary and rights
designations refer to the Insured unless otherwise indicated.
(d)“Policy”, “Insured” and “Policyholder”. For annuities, wherever these words
appear in this form, they mean “Contract”, “Annuitant” and “Contractholder”,
respectively. For Group Universal Life, whenever Policy and Policyholder appear in
this form they mean Certificate and Certificate holder, respectively.
e) RIGHTSHOLDER (OWNER) A person who can exercise rights is a
rightsholder. In contrast, a person designated as contingent rightsholder can only act
upon the death of the primary rightsholder and is not considered a rightsholder until
the happening of that event. Wherever “Rightsholder” appears on this form, it means
“Rightsholder”, “Owner” and “Policyholder”.
2. DETERMINATION OF BENEFICIARY. The beneficiary in Section 1 will
become entitled to the amount payable (proceeds) in the order and proportion stated.
For proceeds payable at the Insured’s death:
Payment made in one sum: Unless otherwise stated, a beneficiary will not be
considered “living” unless the beneficiary is living on the earlier of (a) the day
due proof of the Insured’s death is received by us at our Home Office and (b)
the 14th day after the Insured’s death. The share of the death proceeds of any
beneficiary who is not living on the earlier of these two dates will be payable to
the remaining beneficiaries in the manner provided.
3. TRUST PROVISIONS IN LIVING TRUSTS AND WILLS
A written trust or will cannot change the (terms of your policy or otherwise bind
the Company. Further, the Company cannot determine at any time whether a trust
or will is valid. Accordingly, the Company cannot assume any responsibility for
the trustee’s performance or failure to perform any trust duties and the Company
will not have any further obligations under a policy if il has made a payment to
(or honored a specific request by) a trustee.
4. POLICY ASSIGNMENT
The Interest of any beneficiary or other person will be subordinate to any
assignment whenever made. We may rely solely on the assignee’s statement as to
the amount of ils interest in the death benefit proceeds, which will be payable in
one sum.
5. RIGHTS (OWNERSHIP) UNDER POLICY
Subject to the rights of any assignee, during the Insured’s lifetime and prior to the
date of any endowment proceeds or life income at maturity becoming payable,
the right to change the beneficiary, the right to assign, the right to receive any
endowment proceeds or life income at maturity or to change the payee thereof,
and all other rights, benefits, options, and privileges conferred by the Policy or
allowed by the Company belong exclusively as designated in the application for
this Policy unless otherwise provided by endorsement or as designated in
Section 2 on Page 5.
6. CHANGES IN BENEFICIARY AND RIGHTSHOLDER (OWNER)
These changes may be made during the Insured’s lifetime by written request
to us at our Home Office. The Policy need not be presented for endorsement
unless requested by us. Any such change will take effect as of the date the notice
was signed, upon acceptance and recording at the Home Office, subject to any
payment made by us or action taken by us before receipt of the request at our
Home Office.
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