UNIVERSAL LIFE POLICY MAINTENANCE FORM DEFERRED COMPENSATION PLAN
SECTION 1
UNIVERSAL LIFE POLICY MAINTENANCE FORM DEFERRED COMPENSATION PLAN
Entity Number ______________________________________ Social Security Number
Entity Name __________________________________________________________ Policy Number ______________________
Name
Last
First
MI
Address
Number & Street
Additional Mailing Information
--
City
Home
_
_
Phone
Work Phone
State
Zip Code
_
_
Ext. ________________
NOTE: Changes in Sections 2 & 3 are contingent upon the life company?s approval.
SECTION 2 ? PLAN CHANGES
Check the appropriate box:
r Change from Plan 1 to Plan 2 r Change from Plan 2 to Plan 1
Yes, I have been advised and understand the change of the life plan and how it will affect my death benefit.____________________
(Initial)
SECTION 3 ? SMOKER STATUS CHANGE
If you have not used tobacco in any form in the last twelve months initial the appropriate option.
Medical verification at company expense will be required ? a PortaMedic representative will contact you.
Initial Appropriate Option
____ Decrease my Premium, Death Benefit remains the same (Participation Agreement required) ____ Increase my Death Benefit/Premiums remain the same (minimum increase $10,000 & Life application required)
SECTION 4 ? CANCELLATIONS (Check the appropriate box)
Separation from Service
Actively Employed
Separation from Service Date: ________________________________
Employer Signature: ________________________________________
x
x
H
xH
H
Cancel Life
Cancel Life
Use Cash Value Stop deferral
Coverage:
Coverage:
to obtain Single flow and allow
Refund Cash Refund
Premium
cash surrender
Surrender Value Surrender Value Paid-up Policy value to keep
to Annuity
to the
policy in force
Participant
until value is
exhausted
Cancel Life
Use Cash Value Stop deferral
Coverage:
to obtain Single flow and allow
Refund Cash Premium
cash surrender
Surrender Value Paid-up Policy value to keep
to Annuity
policy in force
until value is
exhausted
r
r
r
r
r
r
r
x Death benefit terminated
H On-going deferrals will be applied and based on current annuity allocation
SECTION 5 ? TRANSFER TO DIRECT PAY
Separation from Service Date: ______________ Signature of Employer: ____________________________________________
r Convert ownership of policy from entity to me. (Any cash surrender value is subject to federal income tax as required by the Internal Revenue Code.)
r Transfer the cash surrender value to annuity, amount of Death Benefit will decrease by the amount of transfer.
Billing Mode: r Monthly Bank Draft r Quarterly
r Semi-Annual
r Annual
Beneficiary Information: Name: ________________________________ Relationship: ________________ Date of Birth: ________
SSN: ________________________ Address: ____________________________________________________________________
NOTE: This change in beneficiary applies to universal life only and will not affect your other beneficiary designations.
I have read and understand the proposed change(s). I hereby request and understand the effective date(s) of such changes is/are contingent upon acceptance by the company.
Participant Signature __________________________________________________________ Date ______________________
NRS Representative __________________________________________________________ Date ______________________
Original ? Life Insurance Company 3 Copy 1 ? NRS 3 Copy 2 ? Participant Nationwide Retirement Solutions 3 PO Box 182797 3 Columbus, OH 43218-2797 3 1-866-827-NMEX(6639) 3 DC-4070-0903
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