National Integrity Life Insurance Company Ownership Change Request Form (NI-77-0039-2505) Instructions

Enter the annuitant's full name (first, middle, last) exactly as it appears on the contract.

Enter the insurance contract or policy number associated with this annuitant as printed on the policy documents.

Check this box if you are not subject to backup withholding under the provisions of Section 3406 (a)(1)(c) of the Internal Revenue Code.

Check this box if the current joint owner's mailing address is the same as the current owner's address, so you do not need to re-enter the address fields for the joint owner.

Enter the current joint owner's street address, including apartment or unit number if applicable. Fill only if 'Same as Owner's' is 'No'.

Enter the current joint owner's city of residence. Fill only if 'Same as Owner's' is 'No'.

Enter the current joint owner's state of residence (use the two-letter state abbreviation if known). Fill only if 'Same as Owner's' is 'No'.

Enter the current joint owner's postal ZIP code (5-digit or ZIP+4). Fill only if 'Same as Owner's' is 'No'.

Enter the current joint owner's full name (first, middle, last) as it appears on legal or account records.

Enter the current joint owner's date of birth.

Enter the current owner's full name including first, middle, and last names as applicable.

Enter the current owner's date of birth.

Enter the current owner's street mailing address, including apartment or suite number if applicable.

Enter the city for the current owner's mailing address.

Enter the current owner's state of residence (use the two-letter postal abbreviation if applicable).

Enter the ZIP or postal code for the current owner's mailing address (include ZIP+4 if available).

Enter the first beneficiary's full name, including first, middle, and last names.

Provide the first beneficiary's date of birth.

Enter the first beneficiary's Social Security Number or Taxpayer Identification Number.

Check this box if the provided identification number for the first beneficiary is a Taxpayer Identification Number (TIN) instead of a Social Security Number.

Provide the first beneficiary's email address.

Enter the first beneficiary's street address.

Enter the city of the first beneficiary's address.

Enter the state of the first beneficiary's address.

Enter the zip code of the first beneficiary's address.

State the first beneficiary's relationship to the annuitant.

Enter the first beneficiary's phone number, including the area code.

Check this box if this first beneficiary is designated as a primary beneficiary.

Check this box if this first beneficiary is designated as a contingent beneficiary.

Enter the percentage of the allocation for the first beneficiary.

Please enter the full name (First, Middle, Last) of the first beneficiary.

Please enter the date of birth of the first beneficiary.

Please enter the Social Security Number or Taxpayer Identification Number of the first beneficiary.

Check this box if the provided identification number for the first beneficiary is a Taxpayer Identification Number (TIN) instead of a Social Security Number.

Please enter the email address of the first beneficiary.

Please enter the street address of the first beneficiary.

Please enter the city of the first beneficiary's address.

Please enter the state of the first beneficiary's address.

Please enter the ZIP code of the first beneficiary's address.

Please enter the relationship of the first beneficiary to the annuitant.

Please enter the phone number of the first beneficiary, including the area code.

Check this box if the first beneficiary is designated as a primary beneficiary.

Check this box if the first beneficiary is designated as a contingent beneficiary.

Please enter the allocation percentage for the first beneficiary.

Enter the spouse's full printed name.

Enter the date the spousal consent is provided.

Check this box when the new joint owner's mailing address is the same as the current owner's address so you do not need to re-enter the address fields. Fill only if 'Add or Change the joint owner' is selected (any).

Enter the street address or P.O. Box for the new joint owner's mailing address, including apartment or unit number if applicable. Fill only if 'Add or Change the joint owner', 'Same as Owner's' is selected and is 'No' (all).

Enter the city for the new joint owner's mailing address. Fill only if 'Add or Change the joint owner', 'Same as Owner's' is selected and is 'No' (all).

Enter the U.S. state for the new joint owner's mailing address, preferably using the two-letter postal abbreviation. Fill only if 'Add or Change the joint owner', 'Same as Owner's' is selected and is 'No' (all).

Enter the ZIP code for the new joint owner's mailing address (5-digit ZIP or ZIP+4). Fill only if 'Add or Change the joint owner', 'Same as Owner's' is selected and is 'No' (all).

Enter the full legal name (first, middle, last) of the new joint owner. Fill only if 'Add or Change the joint owner' is selected (any).

Enter the new joint owner's date of birth. Fill only if 'Add or Change the joint owner' is selected (any).

Enter the new joint owner's Social Security Number or Tax Identification Number as provided on tax records. Fill only if 'Add or Change the joint owner' is selected (any).

Check this box if the number entered in the New Joint Owner's Social Security Number / TIN field is a Taxpayer Identification Number (TIN) rather than a Social Security Number. Fill only if 'Add or Change the joint owner' is selected (any).

Enter the relationship of the new joint owner to the current owner (for example: spouse, child, trustee, friend). Fill only if 'Add or Change the joint owner' is selected (any).

Enter the new joint owner’s daytime phone number including area code so the company can contact them if needed. Fill only if 'Add or Change the joint owner' is selected (any).

Please provide the printed name of the new joint owner, if applicable.

Please provide the date the new joint owner signed the form, if applicable.

Enter the new owner's street address, including apartment or suite number if applicable.

Enter the city for the new owner's address.

Enter the state for the new owner's address, using the two-letter postal abbreviation or full state name.

Enter the postal ZIP code for the new owner's address (five-digit ZIP or ZIP+4).

Enter the new owner's full name (first, middle, last) as it should appear on the contract.

Enter the new owner's date of birth.

Enter the new owner's Social Security Number or Taxpayer Identification Number; if providing a TIN, also check the 'Check if TIN' box.

Check this box when the new owner is providing a Taxpayer Identification Number (TIN) instead of a Social Security Number.

Enter the relationship of the new owner to the current owner (for example: spouse, child, trustee, agent, etc.).

Enter the new owner's primary phone number including area code so we can contact them about the account.

Provide the printed name of the new owner.

Enter the date the new owner signed the form.

Check this box if you are requesting to change the owner of the contract.

Check this box if you are requesting to add a joint owner or change the existing joint owner on the contract.

Check this box if you are requesting to remove the joint owner from the contract.

Check this box if you are requesting to designate a participant owner from a qualified plan for a nontransferable qualified plan distributed annuity.

Check this box when you are requesting a direct rollover from a qualified plan (beginning the rollover selection).

Check this box when you want the qualified plan direct rollover to be deposited into a Traditional IRA. Fill only if 'From Qualified Plan Direct Rollover to' is selected (any).

Check this box when you want the qualified plan direct rollover to be deposited into a Roth IRA. Fill only if 'From Qualified Plan Direct Rollover to' is selected (any).

Please enter the printed full name of the prior joint owner.

Please enter the date the prior joint owner signed the form.

Enter the prior owner's full printed name.

Enter the date the prior owner signed the form.

Enter the full name of the second beneficiary, including first, middle, and last names.

Provide the date of birth for the second beneficiary.

Enter the social security number or taxpayer identification number of the second beneficiary.

Check this box if the identification number provided for the second beneficiary is a Taxpayer Identification Number (TIN).

Provide the email address of the second beneficiary.

Enter the complete street address of the second beneficiary.

Enter the city for the second beneficiary's address.

Enter the state for the second beneficiary's address.

Enter the zip code for the second beneficiary's address.

State the relationship of the second beneficiary to the annuitant.

Provide the phone number of the second beneficiary, including the area code.

Check this box if the second beneficiary is designated as a primary beneficiary.

Check this box if the second beneficiary is designated as a contingent beneficiary.

Enter the percentage of allocation for the second beneficiary.

Please enter the first, middle, and last name of the second beneficiary.

Please provide the date of birth for the second beneficiary.

Please enter the Social Security Number or Taxpayer Identification Number for the second beneficiary.

Check this box if the number provided for the second beneficiary is a Taxpayer Identification Number (TIN) rather than a Social Security Number.

Please enter the email address for the second beneficiary.

Please enter the street address for the second beneficiary.

Please enter the city for the second beneficiary's address.

Please enter the state for the second beneficiary's address.

Please enter the ZIP code for the second beneficiary's address.

Please enter the relationship of the second beneficiary to the annuitant.

Please enter the phone number for the second beneficiary, including the area code.

Check this box if the second beneficiary is designated as a primary beneficiary.

Check this box if the second beneficiary is designated as a contingent beneficiary.

Please enter the percentage of allocation for the second beneficiary.

Enter the full name (first, middle, and last) of the third beneficiary.

Enter the date of birth for the third beneficiary.

Enter the Social Security Number or Taxpayer Identification Number for the third beneficiary.

Check this box if the Third Beneficiary is identified by a Taxpayer Identification Number (TIN) instead of a Social Security Number.

Enter the email address for the third beneficiary.

Enter the street address for the third beneficiary.

Enter the city for the third beneficiary's address.

Enter the state for the third beneficiary's address.

Enter the ZIP code for the third beneficiary's address.

Enter the relationship of the third beneficiary to the annuitant.

Enter the phone number, including the area code, for the third beneficiary.

Check this box if the Third Beneficiary is designated as a primary beneficiary.

Check this box if the Third Beneficiary is designated as a contingent beneficiary, receiving benefits only if the primary beneficiaries are deceased.

Enter the percentage of allocation for the third beneficiary.

Provide the full name of the third beneficiary, including first, middle, and last names.

Enter the date of birth for the third beneficiary.

Provide the Social Security Number or Taxpayer Identification Number for the third beneficiary.

Check this box if the provided Social Security Number / TIN for the third beneficiary is a Taxpayer Identification Number (TIN).

Enter the email address for the third beneficiary.

Provide the street address for the third beneficiary.

Enter the city of residence for the third beneficiary.

Enter the state of residence for the third beneficiary.

Enter the zip code for the third beneficiary.

Describe the relationship of the third beneficiary to the annuitant.

Provide the phone number for the third beneficiary, including the area code.

Check this box if the third beneficiary is designated as a primary beneficiary.

Check this box if the third beneficiary is designated as a contingent beneficiary.

Enter the percentage of allocation for the third beneficiary.

Check this box when the ownership change involving a trust does not meet the criteria of Internal Revenue Code Section 72(e) and you understand any gain will be reported to the IRS as taxable.

Check this box when the ownership change is between you as an individual and the trust and you believe this transaction is not a taxable change of ownership under Internal Revenue Code Section 72(e).