Change of Ownership Form – Life Insurance

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)
Companion
of New York
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_______________________________________
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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.
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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).
Companion Life Insurance Company 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.
Y6501_0503
Please see reverse side
Signed at _____________________________________________ this__________ day of _______________________________.
X ________________________________________________
X ________________________________________________
X ________________________________________________
X ________________________________________________
X ________________________________________________
X ________________________________________________
Personal Signature of Current Owner/Trustee/Donor
Personal Signature of Current Joint Owner (if any)/Joint Trustee (if any)/
Joint Donor (if any)
Personal Signature of New Owner/Trustee/Donee
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)
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)
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: Companion 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
Companion Life Insurance Company is authorized to change, and hereby changes, the Beneficiary(ies) of Policy Number
_____________________ to the person(s)/entity(ies) shown below:
Primary Beneficiary(ies) ______________________________
Tax ID/Social Security No. __________________________
(use Attachment if necessary)
Relationship to Insured ______________________________
Relationship to New Owner(s) ______________________
Contingent Beneficiary(ies) ___________________________
Tax ID/Social Security No. __________________________
(use Attachment if necessary)
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).
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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:
Companion Life Insurance Company:
1-800-733-0662
3316 Farnam Street
Omaha, NE 68175-1100