CHANGE OF OWNERSHIP FORM -

CHANGE OF OWNERSHIP FORM -LIFE INSURANCE
(For Change of Ownership of Life Insurance Policies Only -Do Not Use This Form When Assigning a Policy for a Loan)
NOTE: THE CHANGE OF OWNERSHIP OF A LIFE INSURANCE POLICY MAY HAVE TAX CONSEQUENCES. WE
RECOMMEND THAT YOU CONSULT YOUR TAX ADVISOR WITH ANY QUESTIONS YOU MAY HAVE PRIOR TO
MAKING THIS CHANGE OF OWNERSHIP.
Policy Number ________________________________
Current Owner(s) _______________________________
Current Insured _________________________________
( )
The Current Owner(s) referred to hereafter as the Donor(s), hereby transfer(s) the ownership of the above Policy
with the intention of making a gift. The Donor(s) hereby transfer(s) and assign(s) all right, title and interest in
the above Policy to the New Owner(s) shown below, referred to hereafter as the Donee(s), subject to all of the
terms and conditions of the Policy. The Donor(s) further waive(s) all rights, on behalf of himself/herself or
his/her estate, to receive any benefits whatsoever under the terms of said Policy and direct(s) that if, in the event
such benefits do become payable either to himself/herself or his/her estate under the terms of the Policy, that said
benefits be paid to the estate of the Donee(s) thereunder.
( )
For valuable consideration received, the Current Owner(s) hereby transfer(s) the ownership of the above Policy,
and hereby sell(s) and assign(s) all right, title and interest in the above Policy, to the New Owner(s) shown below,
subject to all of the terms and conditions of the Policy.
1. NEW OWNER* (NOTE: If the New Owner is a Trust,
skip to Paragraph 3. below.)
Name__________________________________________
Relationship ____________________________________
Address ________________________________________
City ___________________ State ______ Zip _______
Tax ID/Social Security No._________________________
Telephone (_____) _______________________________
Age__________ Date of Birth ______________________
2. NEW JOINT OWNER
Name __________________________________________
Relationship _____________________________________
Address ________________________________________
City____________________ State _______ Zip _______
Tax ID/Social Security No. _________________________
Telephone (_____)________________________________
Age__________ Date of Birth_______________________
*If multiple new owners, the policy will be owned as joint tenants
with rights of survivorship and not as tenants in common.
3. NEW OWNER - TRUST
Name of Trust ___________________________________
Date of Trust ____________________________________
Name of Trustee__________________________________
Name of Co-Trustee_______________________________
Trustee Address __________________________________
City_____________________ State _______ Zip ______
Telephone (_____)________________________________
Tax ID/Social Security No. _________________________
(Attach the above information for any Co-Trustee)
If the Current Owner is a Trust, please send a copy of the pages showing that the Trust has been executed and identifying the
Trustee(s) and Successor Trustee(s).
United of Omaha Life Insurance Company/United World Life Insurance Company (whichever is applicable) is not responsible for the
sufficiency or validity of this Change of Ownership. No Change of Ownership shall be binding on us until we receive and record it at
the Company's Home Office. This Change of Ownership is unconditional and irrevocable, and the New Owner(s) shall have the
power to exercise all rights of ownership under said Policy.
Signed at ___________________________________________ this _____________ day of _____________________ .
X__________________________________ X ___________________________________________
Personal Signature of Current Owner/Trustee/Donor
Personal Signature of Spouse of Current Owner/Current Donor residing in a
community property state (CA, AZ, ID, LA, NM, NV, PR, TX, WA, and WI)
X__________________________________ X ___________________________________________
Personal Signature of Current Joint Owner (if any)/Joint Trustee
(if any)/Joint Donor (if any)
Personal Signature of Spouse of Current Joint Owner (if any)/Current Joint Donor (if any),
residing in a community property state (CA, AZ, ID, LA, NM, NV, PR, TX, WA, and WI)
X__________________________________ X ___________________________________________
Personal Signature of New Owner/Trustee/Donee
L6501
Personal Signature of New Joint Owner (if any)/Co-Trustee (if any)/Joint Donee (if any)
________________________________________________________
Date _____________________________
Personal Signature of Irrevocable Beneficiary(ies) (if applicable)
Received and Recorded by:
United of Omaha Life Insurance Company/
United World Life Insurance Company
Date __________________________
NOTICE
The death benefit of the Policy is payable to the Beneficiary(ies) of record. If the New Owner(s)/Trustee(s)/Donee(s)
desire(s) the Beneficiary(ies) to be changed, the New Owner(s)/Trustee(s)/Donee(s) must request this change in accordance
with the policy provisions. The Beneficiary Change Request Form below may be used to change the Beneficiary(ies).
BENEFICIARY CHANGE REQUEST FORM
United of Omaha Life Insurance Company/United World Life Insurance Company (whichever is applicable) is authorized
to change, and hereby changes, the Beneficiary(ies) of Policy Number _____________________________________
to the person(s)/entity(ies) shown below:
Primary Beneficiary(ies) ____________________________
(use Attachment if necessary)
Tax ID/Social Security No. ____________________
Relationship to Insured_____________________________
Relationship to New Owner(s) _________________
Contingent Beneficiary(ies) _________________________
(use Attachment if necessary)
Tax ID/Social Security No. ____________________
Relationship to Insured_____________________________
Relationship to New Owner(s) _________________
No Beneficiary Change shall be binding on us until we receive and record it at the Company's Home Office. Unless you
direct us otherwise, payment of the death benefit will be shared equally by all Primary Beneficiaries who survive the insured.
If no Primary Beneficiaries survive the Insured, payment will be shared equally by all Contingent Beneficiaries who survive
the insured.
This change of Beneficiary hereby revokes all previous Beneficiary designations. The New Owner(s)/Trustee(s)/Donee(s)
reserve(s) the right to further change the Beneficiary(ies).
( )
Irrevocable Beneficiary(ies): If this box is checked, this Policy will be endorsed to show that the Beneficiary(ies)
named above is/are irrevocable, and that no changes to the Policy, including a change of Beneficiary(ies), may be
made by the Owner(s)/Trustee(s)/Donee(s) without the consent of the Beneficiary(ies) shown above.
DATE: __________ NEW OWNER(S)/TRUSTEE(S)/DONEE(S) SIGNATURES:
X ________________________________
X ________________________________
Instructions: Complete this form and return it to:
Individual Life/Annuity: 1-800-775-6000
United of Omaha Life Insurance Company
Policyholder Services
Mutual of Omaha Plaza
Omaha, NE 68175
United World Life Insurance:
1-800-775-6000
United World Life Insurance Company
3316 Farnam Street
Omaha, NE 68172-7218