Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 755 PA (2004/06)
Pennsylvania Life Insurance
Application Supplement -
Additional Owners
Use Pennsylvania Life Insurance Application Supplement - Additional Owners (ACORD
755 PA), when more space is required for Additional Owners.
IDENTIFICATION SECTION Company
Name and Address of Insurance
Name of Insurance Company must be inserted before this form is used. Use the actual
name of the company. Do not use group names.
PROPOSED INSURED
First Name
First name of the proposed insured.
PROPOSED INSURED
Middle Name
Middle name of the proposed insured.
PROPOSED INSURED
Last Name
Last name of the proposed insured.
PROPOSED INSURED
Case ID
Insert the identification number that identifies the case in the agency system.
ADDITIONAL OWNER
Complete only if Owner is to be other than Proposed Insured. Indicate whether a joint
owner or a contingent owner (if applicable)
ADDITIONAL OWNER
Type of Owner
Check the appropriate box to indicate type of owner.
ADDITIONAL OWNER
Name of Trustee
Indicate the name of the Trustee.
ADDITIONAL OWNER
Date of Trust Agreement
Indicate the date of the Trust Agreement. (MM/DD/YYYY)
ADDITIONAL OWNER
First Name
First name of the owner.
ADDITIONAL OWNER
Middle Name
Middle name of the owner.
ADDITIONAL OWNER
Last Name
Last name of the owner.
ADDITIONAL OWNER
Address (No P.O. Box) Line 1
Indicate the address of the owner. Do not use P.O. Box number. Check if this address is
the preferred method of mailing.
ADDITIONAL OWNER
Line 2
Address - Line 2.
ADDITIONAL OWNER
City
Indicate the city of the address.
ADDITIONAL OWNER
State
State of the address.
ADDITIONAL OWNER
Zip
Zip code, postal code, etc. (country dependent)
ADDITIONAL OWNER
Country
Indicate the country of the address.
ADDITIONAL OWNER
Date of Birth
Indicate the date of birth of the producer in MM/DD/YYYY format.
ADDITIONAL OWNER
SSN # / FEIN #
Social security number or Federal Employment Identification Number of the owner.
ADDITIONAL OWNER
Relation To Proposed Insured
Indicate the relation to the proposed insured.
ADDITIONAL OWNER
Full Name
If other than individual, give full name of the owner.
ADDITIONAL OWNER
Are you a citizen of the United
States? Yes or No
Check the appropriate box to indicate whether or not you are a U.S. Citizen. If no,
indicate your country of citizenship.
SIGNATURE
Signature of Additional Owner
Additional Owner must sign the form.
SIGNATURE
Date
Date additional owner signed the form.
SIGNATURE
Signature of Original Owner as
Shown on Part 1 of this
Application
Original Owner must sign the form, if other than proposed insured.
SIGNATURE
Date
Date original owner signed the form.
ACORD 755 PA (2004/06)
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