National Integrity Life Insurance Company Ownership Change Request Form (NI-77-0039-2505) Completed Form Examples and Samples
Explore a clear, filled-out sample of the National Integrity Life Insurance Company Ownership Change Request Form (NI-77-0039-2505). This practical example guides you through the process of changing policy ownership, helping you complete the form accurately.
National Integrity Life Insurance Ownership Change Form Example (NI-77-0039-2505)
How this form was filled:
This example illustrates how to complete the National Integrity Life Insurance Ownership Change Request Form (NI-77-0039-2505) for an absolute assignment of a policy from a parent to an adult child as a gift. It shows the correct completion of sections for the current owner, new owner, and contingent owner.
Information used to fill out the document:
- Policy Number: NI-12345678
- Insured Name: John A. Smith
- Current Owner Name: John A. Smith
- Current Owner Address: 456 Oak Avenue, Anytown, IL 60601
- New Owner Name: Jane M. Smith
- New Owner Address: 789 Pine Street, Somecity, CA 90210
- New Owner Date of Birth: 05/20/1995
- New Owner SSN/TIN: XXX-XX-6789
- New Owner Relationship to Insured: Daughter
- Contingent Owner Name: Mark R. Davis
- Contingent Owner Relationship to New Owner: Spouse
- Type of Change: Absolute Assignment
- Reason for Change: Gift
- Current Owner Signature: John A. Smith
- New Owner Signature: Jane M. Smith
- Date of Signature: 03/10/2026
What this filled form sample shows:
- Clearly identifies the Policy Number and the Insured.
- Specifies the change as an Absolute Assignment, transferring all rights.
- Provides complete details for both the Current Owner and the New Owner, including required signatures.
- Designates a Contingent Owner to succeed the new owner if they predecease the insured.
- Indicates the reason for the change as a 'Gift', which is important for record-keeping and potential tax purposes.
Form specifications and details:
| Form Name: | National Integrity Life Insurance Company Ownership Change Request Form |
| Form Number: | NI-77-0039-2505 |
| Use Case: | Gifting a policy to an adult child (Absolute Assignment) |
Created: January 30, 2026 12:08 AM
