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ACORD 951 (2009/04) rev. 04-30-2009 1 of 13
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Section Name |
Field Name |
Field and/or Section Description |
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TITLE ACORD 951 (2009/04) |
1035 Exchange / Rollover / Transfer Form |
The title of the form. ACORD 951, 1035 Exchange / Rollover / Transfer Form, can be used to accomplish a FULL or a PARTIAL Exchange of policies pursuant to Internal Revenue Code (IRC) Section 1035. This form can also be used for Transfers and Rollovers. Complete the requested information concerning the existing policy and contract, check the appropriate boxes, and date and sign this form. Refer to the application, and if applicable, prospectus and any state required forms for additional important disclosures and information. Check with both the receiving and surrendering company for form requirements specific to the transaction that is being initiated. |
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Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. |
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Use the actual name of the company within the group to which the policy has been issued. |
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This is not the insurer's group name or trade name. As uses here, this is the receiving |
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IDENTIFICATION SECTION |
Receiving Company |
company. |
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IDENTIFICATION SECTION |
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Enter text: The first line of the insurer's mailing address. |
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IDENTIFICATION SECTION |
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Enter text: The second line of the insurer's mailing address. |
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IDENTIFICATION SECTION |
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Enter text: The city of the insurer's mailing address. |
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IDENTIFICATION SECTION |
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Enter code: The state or province of the insurer's mailing address. |
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IDENTIFICATION SECTION |
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Enter code: The postal code of the insurer's mailing address. |
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Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. As used here, this is the existing contract number. This is required when this is a transfer into an existing contract. Without this contract number, the transfer must be made into a new contract. |
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CONTRACT INFORMATION |
Contract Number |
There may be additional state specific forms required. Please confirm the availability of 1035 Exchanges into existing contracts with the Receiving Company. |
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CONTRACT INFORMATION |
Surrendering Company Name |
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer's group name or trade name. As used here this is the surrendering company. Complete one form for each surrendering company. |
ACORD 951 (2009/04) rev. 04-30-2009 2 of 13
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Section Name |
Field Name |
Field and/or Section Description |
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Enter identifier: The identifier assigned by the insurer to the policy, or submission, being |
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referenced exactly as it appears on the policy, including prefix and suffix symbols. If |
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Surrendering Company Account / |
required for self-insurance, the self-insured license or contract number. As used here, this |
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CONTRACT INFORMATION |
Policy / Contract Number |
is the surrendering company account, policy or contract number. |
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Check the box (if applicable): Indicates this is a life insurance policy. As used here, this |
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CONTRACT INFORMATION |
Life Insurance (Checkbox) |
refers to the surrendering company account, policy or contract number. |
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Check the box (if applicable): Indicates this is an annuity contract. As used here, this |
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CONTRACT INFORMATION |
Annuity Contract (Checkbox) |
refers to the surrendering company account, policy or contract number. |
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Check the box (if applicable): Indicates this is a contract type other than those listed. As |
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CONTRACT INFORMATION |
Other (Checkbox) |
used here, this refers to the surrendering company account, policy or contract number. |
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Enter text: The description of the contract type. As used here, this refers to the |
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CONTRACT INFORMATION |
Other |
surrendering company account, policy or contract number. |
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Enter number: The area code of the primary phone number of the insurer. As used here, |
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CONTRACT INFORMATION |
Area Code |
this refers to the surrendering company. |
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Enter number: The primary phone number of the insurer. As used here, this refers to the |
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CONTRACT INFORMATION |
Phone Number |
surrendering company. |
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Enter number: The extension of the primary phone number of the insurer. As used here, |
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CONTRACT INFORMATION |
Ext |
this refers to the surrendering company. |
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Street Address (No P.O. Box) Line |
Enter text: The first line of the insurer's mailing address. As used here, this refers to the |
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CONTRACT INFORMATION |
1 |
surrendering company. |
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Enter text: The second line of the insurer's mailing address. As used here, this refers to |
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CONTRACT INFORMATION |
Line 2 |
the surrendering company. |
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Enter text: The city of the insurer's mailing address. As used here, this refers to the |
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CONTRACT INFORMATION |
City |
surrendering company. |
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Enter code: The state or province of the insurer's mailing address. As used here, this |
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CONTRACT INFORMATION |
State |
refers to the surrendering company. |
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Enter code: The postal code of the insurer's mailing address. As used here, this refers to |
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CONTRACT INFORMATION |
Zip |
the surrendering company. |
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POLICY / ACCOUNT / |
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Enter text: The named insured's given name. As used here, this is the surrendering |
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CONTRACT INFORMATION |
First Name / Entity Name |
company account, policy or contract owner.. |
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POLICY / ACCOUNT / |
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Enter text: The named insured's other given name initial. As used here, this is the |
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CONTRACT INFORMATION |
Middle Initial |
surrendering company account, policy or contract owner.. |
ACORD 951 (2009/04) rev. 04-30-2009 3 of 13
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Section Name |
Field Name |
Field and/or Section Description |
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POLICY / ACCOUNT / |
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Enter text: The named insured's surname. As used here, this is the surrendering company |
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CONTRACT INFORMATION |
Last Name |
account, policy or contract owner.. |
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POLICY / ACCOUNT / |
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Enter identifier: The tax identifier of the named insured. As used here, this is the |
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CONTRACT INFORMATION |
SSN # / Tax ID # |
surrendering company account, policy or contract owner.. |
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Enter text: The named insured's given name. As used here, this is the surrendering |
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POLICY / ACCOUNT / |
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company account, policy or contract joint owner. Please confirm the availability of these |
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CONTRACT INFORMATION |
Joint Owner First Name |
options with the receiving company. |
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POLICY / ACCOUNT / |
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Enter text: The named insured's other given name initial. As used here, this is the |
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CONTRACT INFORMATION |
Joint Owner Middle Name |
surrendering company account, policy or contract joint owner. |
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POLICY / ACCOUNT / |
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Enter text: The named insured's surname. As used here, this is the surrendering company |
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CONTRACT INFORMATION |
Joint Owner Last Name |
account, policy or contract joint owner. |
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POLICY / ACCOUNT / |
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Enter identifier: The tax identifier of the named insured. As used here, this is the |
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CONTRACT INFORMATION |
Joint Owner SSN # / Tax ID # |
surrendering company account, policy or contract joint owner. |
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POLICY / ACCOUNT / |
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Enter text: The named insured's given name. As used here, this is the surrendering |
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CONTRACT INFORMATION |
Insured/Annuitant First Name |
company account, policy or contract insured / annuitant. |
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POLICY / ACCOUNT / |
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Enter text: The named insured's other given name initial. As used here, this is the |
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CONTRACT INFORMATION |
Insured/Annuitant Middle Name |
surrendering company account, policy or contract insured / annuitant. |
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POLICY / ACCOUNT / |
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Enter text: The named insured's surname. As used here, this is the surrendering company |
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CONTRACT INFORMATION |
Insured/Annuitant Last Name |
account, policy or contract insured / annuitant. |
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POLICY / ACCOUNT / |
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Enter identifier: The tax identifier of the named insured. As used here, this is the |
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CONTRACT INFORMATION |
Insured/Annuitant SSN # / Tax ID # |
surrendering company account, policy or contract insured / annuitant. |
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Enter text: The named insured's given name. As used here, this is the surrendering |
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POLICY / ACCOUNT / |
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company account, policy or contract joint insured / annuitant. Please confirm the |
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CONTRACT INFORMATION |
Joint Insured/Annuitant First Name |
availability of these options with the receiving company. |
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POLICY / ACCOUNT / |
Joint Insured/Annuitant Middle |
Enter text: The named insured's other given name initial. As used here, this is the |
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CONTRACT INFORMATION |
Name |
surrendering company account, policy or contract joint insured / annuitant. |
ACORD 951 (2009/04) rev. 04-30-2009 4 of 13
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Section Name |
Field Name |
Field and/or Section Description |
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POLICY / ACCOUNT / |
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Enter text: The named insured's surname. As used here, this is the surrendering company |
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CONTRACT INFORMATION |
Joint Insured/Annuitant Last Name |
account, policy or contract joint insured / annuitant. |
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POLICY / ACCOUNT / |
Joint Insured/Annuitant SSN # / |
Enter identifier: The tax identifier of the named insured. As used here, this is the |
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CONTRACT INFORMATION |
Tax ID # |
surrendering company account, policy or contract joint insured / annuitant. |
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Enter text: The named insured's given name. As used here, this is the surrendering |
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POLICY / ACCOUNT / |
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company account, policy or contract contingent annuitant. Please confirm the availability |
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CONTRACT INFORMATION |
Contingent Annuitant First Name |
of these options with the receiving company. |
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POLICY / ACCOUNT / |
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Enter text: The named insured's other given name initial. As used here, this is the |
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CONTRACT INFORMATION |
Contingent Annuitant Middle Name |
surrendering company account, policy or contract contingent annuitant. |
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POLICY / ACCOUNT / |
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Enter text: The named insured's surname. As used here, this is the surrendering company |
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CONTRACT INFORMATION |
Contingent Annuitant Last Name |
account, policy or contract contingent annuitant. |
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POLICY / ACCOUNT / |
Contingent Annuitant SSN # / Tax |
Enter identifier: The tax identifier of the named insured. As used here, this is the |
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CONTRACT INFORMATION |
ID # |
surrendering company account, policy or contract contingent annuitant. |
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NON-QUALIFIED ANNUITY, |
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ENDOWMENT OR LIFE |
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INSURANCE CONTRACT: |
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AUTHORIZATION FOR |
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1035(a) TAX-FREE |
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Check the box (if applicable): Indicates a full exchange. Please confirm the availability of |
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EXCHANGE |
Full Exchange (Checkbox) |
this option with both the surrendering and receiving company. |
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NON-QUALIFIED ANNUITY, ENDOWMENT OR LIFE INSURANCE CONTRACT: AUTHORIZATION FOR 1035(a) TAX-FREE EXCHANGE |
Loan Carry Forward (Not available for annuities) (Checkbox) |
Check the box (if applicable): Indicates a loan carry forward (not available for annuities). Please confirm the availability of this option with both the surrendering and receiving company. |
ACORD 951 (2009/04) rev. 04-30-2009 5 of 13
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Section Name |
Field Name |
Field and/or Section Description |
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NON-QUALIFIED ANNUITY, |
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ENDOWMENT OR LIFE |
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INSURANCE CONTRACT: |
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AUTHORIZATION FOR |
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1035(a) TAX-FREE |
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EXCHANGE |
Specify Loan Amount ($) |
Enter amount: The amount of the loan to be carried forward. |
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NON-QUALIFIED ANNUITY, |
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ENDOWMENT OR LIFE |
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INSURANCE CONTRACT: |
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AUTHORIZATION FOR |
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1035(a) TAX-FREE |
Modified Endowment Contract |
Check the box (if applicable): Indicates a modified endowment contract. Please confirm |
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EXCHANGE |
(Checkbox) |
the availability of this option with both the surrendering and receiving company. |
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NON-QUALIFIED ANNUITY, ENDOWMENT OR LIFE INSURANCE CONTRACT: AUTHORIZATION FOR 1035(a) TAX-FREE EXCHANGE |
Partial Exchange (Checkbox) |
Check the box (if applicable): Indicates a partial exchange. Please confirm the availability of this option with both the surrendering and receiving company. Applicable to annuity contracts only. |
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NON-QUALIFIED ANNUITY, |
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ENDOWMENT OR LIFE |
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INSURANCE CONTRACT: |
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AUTHORIZATION FOR |
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1035(a) TAX-FREE |
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EXCHANGE |
1035 Exchange ($) Or |
Enter amount: The amount of the partial exchange. |
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NON-QUALIFIED ANNUITY, |
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ENDOWMENT OR LIFE |
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INSURANCE CONTRACT: |
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AUTHORIZATION FOR |
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1035(a) TAX-FREE |
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EXCHANGE |
1035 Exchange % |
Enter percentage: The percentage of the partial exchange. |
ACORD 951 (2009/04) rev. 04-30-2009 6 of 13
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Section Name |
Field Name |
Field and/or Section Description |
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NON-QUALIFIED ANNUITY, ENDOWMENT OR LIFE INSURANCE CONTRACT: AUTHORIZATION FOR 1035(a) TAX-FREE EXCHANGE |
Penalty Free Amount |
Check the box (if applicable): Indicates the exchange is a penalty free amount. The amount is subject to change based on the product provisions. Check with the surrendering company to verify the amount. Please confirm the availability of this option with both the surrendering and receiving company. |
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TRANSFER OF FUNDS FROM NON-INSURANCE ACCOUNTS TO NONQUALIFIED ANNUITIES |
Mutual Fund Shares (Checkbox) |
Check the box (if applicable): Indicates the transfer of mutual fund shares to non-qualified annuities. Please confirm the availability of this option with both the surrendering and receiving company. Applicable to annuity contracts only. |
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TRANSFER OF FUNDS FROM NON-INSURANCE ACCOUNTS TO NONQUALIFIED ANNUITIES |
Certificates of Deposit (Checkbox) |
Check the box (if applicable): Indicates the transfer of a certificate of deposit to non-qualified annuities. Please confirm the availability of this option with both the surrendering and receiving company. Applicable to annuity contracts only. |
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TRANSFER OF FUNDS FROM NON-INSURANCE ACCOUNTS TO NONQUALIFIED ANNUITIES |
Brokerage Account (Checkbox) |
Check the box (if applicable): Indicates the transfer of brokerage account to non-qualified annuities. Please confirm the availability of this option with both the surrendering and receiving company. Applicable to annuity contracts only. |
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TRANSFER OF FUNDS FROM NON-INSURANCE ACCOUNTS TO NONQUALIFIED ANNUITIES |
Investment Description-Line1 |
Enter text: The description of the investment of the assets to be transferred. |
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TRANSFER OF FUNDS FROM NON-INSURANCE ACCOUNTS TO NONQUALIFIED ANNUITIES |
Entire Value (Checkbox) |
Check the box (if applicable): Indicates the entire value is being transferred to non-qualified annuities. |
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TRANSFER OF FUNDS FROM NON-INSURANCE ACCOUNTS TO NONQUALIFIED ANNUITIES |
Partial Value (Checkbox) |
Check the box (if applicable): Indicates a partial value is being transferred to non-qualified annuities. |
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TRANSFER OF FUNDS FROM NON-INSURANCE ACCOUNTS TO NONQUALIFIED ANNUITIES |
In the amount of ($) |
Enter amount: The amount to be transferred to non-qualified annuities. |
ACORD 951 (2009/04) rev. 04-30-2009 7 of 13
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Section Name |
Field Name |
Field and/or Section Description |
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TRANSFER OF FUNDS FROM NON-INSURANCE ACCOUNTS TO NONQUALIFIED ANNUITIES |
% |
Enter percentage: The percentage of funds to be transferred to non-qualified annuities. |
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TAX-QUALIFIED RETIREMENT ACCOUNTS / CONTRACTS REQUEST FOR DIRECT ROLLOVER / TRANSFER |
Traditional IRA (Checkbox) |
Check the box (if applicable): Indicates a traditional individual retirement account (IRA). As used here, indicates the account the funds are being transferred from. Please confirm the availability of this option with both the surrendering and receiving company. |
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TAX-QUALIFIED RETIREMENT ACCOUNTS / CONTRACTS REQUEST FOR DIRECT ROLLOVER / TRANSFER |
SEP-IRA (Checkbox) |
Check the box (if applicable): Indicates a simplified employee pension plan (SEP - IRA). As used here, indicates the account the funds are being transferred from. Please confirm the availability of this option with both the surrendering and receiving company. |
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TAX-QUALIFIED RETIREMENT ACCOUNTS / CONTRACTS REQUEST FOR DIRECT ROLLOVER / TRANSFER |
SIMPLE IRA (Checkbox) |
Check the box (if applicable): Indicates a saving incentive match plan (SIMPLE IRA). As used here, indicates the account the funds are being transferred from. Please confirm the availability of this option with both the surrendering and receiving company. |
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TAX-QUALIFIED RETIREMENT ACCOUNTS / CONTRACTS REQUEST FOR DIRECT ROLLOVER / TRANSFER |
Roth IRA (Checkbox) |
Check the box (if applicable): Indicates a Roth individual retirement account (Roth IRA). As used here, indicates the account the funds are being transferred from. Please confirm the availability of this option with both the surrendering and receiving company. ** Roth IRA funds can be transferred only to another Roth IRA. |
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TAX-QUALIFIED RETIREMENT ACCOUNTS / CONTRACTS REQUEST FOR DIRECT ROLLOVER / TRANSFER |
Pension Plan (Checkbox) |
Check the box (if applicable): Indicates a pension plan. As used here, indicates the account the funds are being transferred from. Please confirm the availability of this option with both the surrendering and receiving company. |
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TAX-QUALIFIED RETIREMENT ACCOUNTS / CONTRACTS REQUEST FOR DIRECT ROLLOVER / TRANSFER |
401(a) (Checkbox) |
Check the box (if applicable): Indicates a 401(a). As used here, indicates the account the funds are being transferred from. Please confirm the availability of this option with both the surrendering and receiving company. |
ACORD 951 (2009/04) rev. 04-30-2009 8 of 13
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Section Name |
Field Name |
Field and/or Section Description |
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TAX-QUALIFIED |
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RETIREMENT ACCOUNTS / |
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CONTRACTS REQUEST |
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Check the box (if applicable): Indicates a 401(k). As used here, indicates the account the |
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FOR DIRECT ROLLOVER / |
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funds are being transferred from. Please confirm the availability of this option with both |
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TRANSFER |
401(k) (Checkbox) |
the surrendering and receiving company. |
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TAX-QUALIFIED |
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RETIREMENT ACCOUNTS / |
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CONTRACTS REQUEST |
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Check the box (if applicable): Indicates a 401(k) designated Roth account. As used here, |
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FOR DIRECT ROLLOVER / |
401(k) Designated Roth Account |
indicates the account the funds are being transferred from. Please confirm the availability |
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TRANSFER |
(Checkbox) |
of this option with both the surrendering and receiving company. |
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TAX-QUALIFIED |
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RETIREMENT ACCOUNTS / |
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CONTRACTS REQUEST |
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Check the box (if applicable): Indicates a 457(b). As used here, indicates the account the |
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FOR DIRECT ROLLOVER / |
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funds are being transferred from. Please confirm the availability of this option with both |
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TRANSFER |
457(b) Plan (Checkbox) |
the surrendering and receiving company. |
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TAX-QUALIFIED RETIREMENT ACCOUNTS / CONTRACTS REQUEST FOR DIRECT ROLLOVER / TRANSFER |
TSA/403 B (Checkbox) |
Check the box (if applicable): Indicates a tax sheltered annuity 403(b).� * All existing TSA loans must be reconciled with your current carrier prior to transfer. As used here, indicates the account the funds are being transferred from. Please confirm the availability of this option with both the surrendering and receiving company. * All existing TSA loans must be reconciled with your current carrier prior to the transfer. |
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TAX-QUALIFIED |
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RETIREMENT ACCOUNTS / |
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CONTRACTS REQUEST |
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Check the box (if applicable): Indicates an account other than those listed. As used here, |
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FOR DIRECT ROLLOVER / |
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indicates the account the funds are being transferred from. Please confirm the availability |
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TRANSFER |
Other (Checkbox) |
of this option with both the surrendering and receiving company. |
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TAX-QUALIFIED |
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RETIREMENT ACCOUNTS / |
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CONTRACTS REQUEST |
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Enter text: The description of the type of account. As used here, indicates the account the |
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FOR DIRECT ROLLOVER / |
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funds are being transferred from. Please confirm the availability of this option with both |
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TRANSFER |
Other Description Field |
the surrendering and receiving company. |
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TAX-QUALIFIED |
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RETIREMENT ACCOUNTS / |
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CONTRACTS REQUEST |
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Check the box (if applicable): Indicates the entire value of the tax qualified retirement |
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FOR DIRECT ROLLOVER / |
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account / contract is to be rolled over / transferred. Please confirm the availability of this |
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TRANSFER |
Entire Value (Checkbox) |
option with both the surrendering and receiving company. |
ACORD 951 (2009/04) rev. 04-30-2009 9 of 13
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Section Name |
Field Name |
Field and/or Section Description |
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TAX-QUALIFIED |
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RETIREMENT ACCOUNTS / |
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CONTRACTS REQUEST |
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Check the box (if applicable): Indicates a partial value of the tax qualified retirement |
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FOR DIRECT ROLLOVER / |
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account / contract is to be rolled over / transferred. Please confirm the availability of this |
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TRANSFER |
Partial Value (Checkbox) |
option with both the surrendering and receiving company. |
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TAX-QUALIFIED |
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RETIREMENT ACCOUNTS / |
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CONTRACTS REQUEST |
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FOR DIRECT ROLLOVER / |
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Enter amount: The partial amount of the tax qualified retirement account / contract to be |
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TRANSFER |
In the amount of ($) |
rolled over / transferred. |
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TAX-QUALIFIED |
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RETIREMENT ACCOUNTS / |
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CONTRACTS REQUEST |
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FOR DIRECT ROLLOVER / |
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Enter percentage: The percentage of the tax qualified retirement account / contract to be |
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TRANSFER |
% |
rolled over / transferred. |
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TAX-QUALIFIED RETIREMENT ACCOUNTS / CONTRACTS REQUEST FOR DIRECT ROLLOVER / TRANSFER |
Penalty Free Amount |
Check the box (if applicable): Indicates a penalty free amount of the tax qualified retirement account / contract is to be rolled over / transferred. The amount is subject to change based on the product provisions. Please check with the surrendering company to verify the amount. Please confirm the availability of this option with both the surrendering and receiving company. |
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SPECIAL INSTRUCTIONS |
Special Instructions for |
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FOR LIQUIDATING |
Liquidating Existing Contract or |
Check the box (if applicable): Indicates the funds will be liquidated as soon as possible |
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EXISTING CONTRACT OR |
Account (As soon as possible) |
after the receipt of all necessary forms. If no option is selected, the funds will be liquidated |
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ACCOUNT |
(Checkbox) |
as soon as possible. |
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SPECIAL INSTRUCTIONS |
Special Instructions for |
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FOR LIQUIDATING |
Liquidating Existing Contract or |
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EXISTING CONTRACT OR |
Account (On a specific date) |
Check the box (if applicable): Indicate if funds will be liquidated on a specific date. If no |
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ACCOUNT |
(Checkbox) |
option is selected, the funds will be liquidated as soon as possible. |
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SPECIAL INSTRUCTIONS |
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FOR LIQUIDATING |
Special Instructions for |
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EXISTING CONTRACT OR |
Liquidating Existing Contract or |
Enter date: The date the funds will be liquidated. The date must be prior to the maturity |
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ACCOUNT |
Account (On a specific date) |
date of the existing contract. |
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SPECIAL INSTRUCTIONS |
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FOR LIQUIDATING |
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EXISTING CONTRACT OR |
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Check the box (if applicable): Indicates the funds will be liquidated on the maturity date. If |
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ACCOUNT |
At maturity date |
no option is selected, the funds will be liquidated as soon as possible. |
ACORD 951 (2009/04) rev. 04-30-2009 10 of 13
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Section Name |
Field Name |
Field and/or Section Description |
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SPECIAL INSTRUCTIONS |
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FOR LIQUIDATING |
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EXISTING CONTRACT OR |
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ACCOUNT |
Transfer Date / Maturity Date |
Enter date: The maturity date on which the funds will be liquidated. |
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Signature of Owner / Plan |
Sign here: Accommodates the signature of the applicant or named insured. As used here, |
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SIGNATURES |
Administrator / Trustee |
this is the signature of the owner, plan administrator or trustee. |
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SIGNATURES |
Date |
Enter date: The date the form was signed by the named insured. |
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Signature of Joint Owner / Co- |
Sign here: Accommodates the signature of the applicant or named insured. As used here, |
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SIGNATURES |
Trustee (If applicable). |
this is the signature of the joint owner or co-trustee (if applicable). |
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SIGNATURES |
Date |
Enter date: The date the form was signed by the named insured. |
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Signature of Proposed Insured |
Sign here: Accommodates the signature of the applicant or named insured. As used here, |
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SIGNATURES |
(Life Only) |
this is the signature of the proposed insured (life only). |
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SIGNATURES |
Date |
Enter date: The date the form was signed by the named insured. |
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Signature of Spouse (Required in |
Sign here: Accommodates the signature of the applicant or named insured. As used here, |
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AZ, CA, ID, LA, NV, NM, TX, WA |
this is the signature of the spouse. This is required in AZ, CA, ID, LA, NV, NM, TX, WA |
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SIGNATURES |
and WI only) |
and WI only). |
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SIGNATURES |
Date |
Enter date: The date the form was signed by the named insured. |
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Signature of Irrevocable |
Sign here: Accommodates the signature of the applicant or named insured. As used here, |
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SIGNATURES |
Beneficiary (If applicable). |
this is the signature of the irrevocable beneficiary (if applicable). |
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SIGNATURES |
Date |
Enter date: The date the form was signed by the named insured. |
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Print Name of Employer or Third |
Enter text: The employer name (business name if self-employed). As used here, the name |
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SIGNATURES |
Party Administrator |
of the employer or third party administrator. Required for TSA / 403(b) transfers only. |
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Title of Employer or Third Party |
Enter text: The title of the authorized representative of the employer. As used here, the |
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SIGNATURES |
Administrator |
title of the employer or third party administrator. Required for TSA / 403(b) transfers only. |
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Signature of Employer or Third |
Sign here: Accommodates the signature of the authorized representative of the employer. As used here, the signature of the employer or third party administrator. Required for TSA |
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SIGNATURES |
Party Administrator |
/ 403(b) transfers only. |
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Enter date: The date the form was signed by the employer. As used here, the date the |
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employer or third party administrator signed the form. Required for TSA / 403(b) transfers |
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SIGNATURES |
Date (mm/dd/yyyy) |
only. |
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REMARKS |
Remarks |
Enter text: The remarks associated with the Exchange / Rollover / Transfer Form. |
ACORD 951 (2009/04) rev. 04-30-2009 11 of 13
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Section Name |
Field Name |
Field and/or Section Description |
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ACCEPTANCE OF ASSIGNMENT / TRUSTEE TRANSFER / DIRECT ROLLOVER - For The Company's use only |
Traditional IRA (Checkbox) |
Check the box (if applicable): Indicates a traditional individual retirement account (IRA). As used here, indicates the type of account in which the receiving company will place the assets upon receipt. |
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ACCEPTANCE OF ASSIGNMENT / TRUSTEE TRANSFER / DIRECT ROLLOVER - For The Company's use only |
SEP-IRA (Checkbox) |
Check the box (if applicable): Indicates a simplified employee pension plan (SEP - IRA). As used here, indicates the type of account in which the receiving company will place the assets upon receipt. |
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ACCEPTANCE OF ASSIGNMENT / TRUSTEE TRANSFER / DIRECT ROLLOVER - For The Company's use only |
SIMPLE IRA (Checkbox) |
Check the box (if applicable): Indicates a saving incentive match plan (SIMPLE IRA). As used here, indicates the type of account in which the receiving company will place the assets upon receipt. |
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ACCEPTANCE OF ASSIGNMENT / TRUSTEE TRANSFER / DIRECT ROLLOVER - For The Company's use only |
Roth IRA (Checkbox) |
Check the box (if applicable): Indicates a Roth individual retirement account (Roth IRA). As used here, indicates the type of account in which the receiving company will place the assets upon receipt. |
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ACCEPTANCE OF ASSIGNMENT / TRUSTEE TRANSFER / DIRECT ROLLOVER - For The Company's use only |
Pension Plan (Checkbox) |
Check the box (if applicable): Indicates a pension plan. As used here, indicates the type of account in which the receiving company will place the assets upon receipt. |
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ACCEPTANCE OF ASSIGNMENT / TRUSTEE TRANSFER / DIRECT ROLLOVER - For The Company's use only |
401(a) (Checkbox) |
Check the box (if applicable): Indicates a 401(a). As used here, indicates the type of account in which the receiving company will place the assets upon receipt. |
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ACCEPTANCE OF ASSIGNMENT / TRUSTEE TRANSFER / DIRECT ROLLOVER - For The Company's use only |
401(k) (Checkbox) |
Check the box (if applicable): Indicates a 401(k). As used here, indicates the type of account in which the receiving company will place the assets upon receipt. |
ACORD 951 (2009/04) rev. 04-30-2009 12 of 13
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Section Name |
Field Name |
Field and/or Section Description |
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ACCEPTANCE OF |
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ASSIGNMENT / TRUSTEE |
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TRANSFER / DIRECT |
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Check the box (if applicable): Indicates a 401(k) designated Roth account. As used here, |
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ROLLOVER - For The |
401(k) Designated Roth Account |
indicates the type of account in which the receiving company will place the assets upon |
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Company's use only |
(Checkbox) |
receipt. |
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ACCEPTANCE OF |
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ASSIGNMENT / TRUSTEE |
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TRANSFER / DIRECT |
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ROLLOVER - For The |
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Check the box (if applicable): Indicates a 457(b). As used here, indicates the type of |
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Company's use only |
457(b) Plan (Checkbox) |
account in which the receiving company will place the assets upon receipt. |
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ACCEPTANCE OF |
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ASSIGNMENT / TRUSTEE |
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Check the box (if applicable): Indicates a tax sheltered annuity 403(b).� |
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TRANSFER / DIRECT |
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* All existing TSA loans must be reconciled with your current carrier prior to transfer. As |
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ROLLOVER - For The |
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used here, indicates the type of account in which the receiving company will place the |
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Company's use only |
TSA/403 B (Checkbox) |
assets upon receipt. |
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ACCEPTANCE OF |
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ASSIGNMENT / TRUSTEE |
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TRANSFER / DIRECT |
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Check the box (if applicable): Indicates an account other than those listed. As used here, |
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ROLLOVER - For The |
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indicates the type of account in which the receiving company will place the assets upon |
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Company's use only |
Other (Checkbox) |
receipt. |
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ACCEPTANCE OF |
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ASSIGNMENT / TRUSTEE |
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TRANSFER / DIRECT |
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ROLLOVER - For The |
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Enter text: The description of the type of account. As used here, indicates the type of |
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Company's use only |
Other Description Field |
account in which the receiving company will place the assets upon receipt. |
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ACCEPTANCE OF |
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ASSIGNMENT / TRUSTEE |
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TRANSFER / DIRECT |
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ROLLOVER - For The |
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Company's use only |
Account # |
Enter identifier: The account number of the deposited assets. |
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ACCEPTANCE OF |
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ASSIGNMENT / TRUSTEE |
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TRANSFER / DIRECT |
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ROLLOVER - For The |
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Enter text: The full name of the authorized officer of the insurer. As used here, this is the |
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Company's use only |
Print Name of Authorized Officer |
authorized officer of the receiving company. |
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Section Name |
Field Name |
Field and/or Section Description |
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ACCEPTANCE OF ASSIGNMENT / TRUSTEE TRANSFER / DIRECT ROLLOVER - For The Company's use only |
Title of Authorized Officer |
Enter text: The title of the authorized officer. As used here, this is the authorized officer of the receiving company. |
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ACCEPTANCE OF ASSIGNMENT / TRUSTEE TRANSFER / DIRECT ROLLOVER - For The Company's use only |
Signature of Authorized Officer |
Sign here: Accommodates the signature of the authorized officer. As used here, this is the authorized officer of the receiving company. |
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ACCEPTANCE OF ASSIGNMENT / TRUSTEE TRANSFER / DIRECT ROLLOVER - For The Company's use only |
Date (mm/dd/yyyy) |
Enter date: The date the form was signed by the authorized officer. As used here, this is the authorized officer of the receiving company. |
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Edition |
Date |
The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM). |
ACORD 951 (2009/04) rev. 04-30-2009 13 of 13
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