1 United of Omaha Life Insurance Company A Mutual of Omaha Company Change of Ownership/Beneficiary Forms Packet Contains Life Insurance Change of Ownership Form Life Insurance Application for Change of Beneficiary L8528
2 Change of Ownership Form Life Insurance (For Change of Ownership of Life Insurance Policies Only Do Not Use This Form When Assigning a Policy for a Loan) Instructions: Complete this form and return it to: Individual Life: Fax to: United of Omaha Life Insurance Company Attn: Policyowner Services Policyholder Services Mutual of Omaha Plaza Omaha, NE Note: The change of ownership of a life insurance policy may have tax consequences. We recommend that you consult your tax advisor with any questions you may have prior to making this change of ownership. Policy Number Current Owner (s) Current Insured By checking one of the boxes below. The Current Owner(s) further waive(s) all rights, on behalf of himself/herself or his/her estate, to receive any benefits whatsoever under the terms of said Policy and direct(s) that if, in the event such benefits do become payable either to himself/herself or his/her estate under the terms of the Policy, that said benefits be paid to the estate of the New Owner(s) thereunder. The Current Owner(s), hereby transfer(s) the ownership of the above Policy with the intention of making a gift. The Current Owner(s) hereby transfer(s) all right, title and interest in the above Policy to the New Owner(s) shown below, subject to all of the terms and conditions of the Policy. For valuable consideration received, the Current Owner(s) hereby transfer(s) the ownership of the above Policy, and hereby transfer(s) all right, title and interest in the above Policy to the New Owner(s) shown below, subject to all of the terms and conditions of the Policy. 1. NEW OWNER* (Note: If the New Owner is a Trust, skip to Paragraph 3. below.) Name Relationship Address City State ZIP Tax ID/Social Security No. Telephone Age Date of Birth *If multiple New Owners, the policy will be owned as joint tenants with rights of survivorship and not as tenants in common. 3. NEW OWNER TRUST Name of Trust Date of Trust Name of Trustee Name of Co-Trustee 2. NEW JOINT OWNER Name Relationship Address City State ZIP Tax ID/Social Security No. Telephone Age Date of Birth Trustee Address City State ZIP Tax ID/Social Security No. Telephone (Attach the above information for any Co-Trustee) If the Current Owner is a Trust, please send a copy of the pages showing that the Trust has been executed and identifying the Trustee(s) and Successor Trustee(s). L6501_1212 Please see reverse side
3 Authorized Signature: United of Omaha Life Insurance Company is not responsible for the sufficiency or validity of this Change of Ownership. No Change of Ownership shall be binding on us until we receive and record it at the company s home office. This Change of Ownership is unconditional and irrevocable, and the New Owner(s) shall have the power to exercise all rights of ownership under said Policy. Notice The death benefit of the Policy is payable to the Beneficiary(ies) of record. If the New Owner(s)/Trustee(s) desire(s) the Beneficiary(ies) to be changed, the New Owner(s)/Trustee(s) must request this change in accordance with the Policy Provisions. The Beneficiary Change Request Form included may be used to change the Beneficiary(ies). Personal Signature of Current Owner/Trustee Personal Signature of New Owner/Trustee _ Personal Signature of Current Joint Owner/Trustee (if any) _ Personal Signature of New Joint Owner/Trustee (if any) Signed at this day of. (City and State) Party-in-Interest Consent: IMPORTANT INFORMATION THAT MAY IMPACT YOU: Do you live in a community property state? CA, AZ, ID, NV, PR, TX, WA, LA, NM and WI If you are the Current Owner of this Policy and reside in one of the states listed above and want to change the ownership of this contract, your spouse s consent may be required and your spouse must sign as Party-in-Interest below. If this change is a result of marriage, divorce or death, we require a copy of your marriage certificate, divorce decree or death certificate. Personal Signature of Party-in-Interest of Current Owner/Trustee _ Personal Signature of Party-in-Interest of Joint Owner/ Trustee (if any) Signed at this day of. (City and State) Irrevocable Beneficiary Consent: Do you have an Irrevocable Beneficiary named? If you are the Current Owner of this Policy and have previously named an irrevocable beneficiary, the irrevocable beneficiary(ies) consent is required and must sign as Irrevocable Beneficiary below. Personal Signature of Irrevocable Beneficiary(ies) (if applicable) _ Personal Signature of Irrevocable Beneficiary(ies) (if applicable) Signed at this day of. (City and State) L6501_1212
4 Application for Change of Beneficiary Mutual of Omaha Insurance Company and Insurance Affiliates* Mutual of Omaha Plaza Omaha, NE *United of Omaha LIfe Insurance Company United World Life Insurance Company Omaha Insurance Company Instructions for Completing the Change of Beneficiary Form The Change of Beneficiary Form is attached. Examples of wording that can be used to designate a beneficiary on this Form are set forth below. If the policy proceeds are to be paid other than in a single sum, do not use this form and contact United of Omaha Life Insurance Company for further instructions. Type of Beneficiary Sample Wording 1. Single Named Person... Jane Doe, wife 2. Two or more named persons in equal shares... John Doe, father, and Mary Doe, mother, in equal shares 3. Two or more named persons in unequal shares percent to John Doe, father, and 60 percent to Mary Doe, mother [do not use dollar amounts] 4. Unnamed children of a specified marriage... Children of the marriage of the Insured (excluding children by a previous marriage, and Jane Doe foster children and stepchildren) 5. Trustee under Last Will and Testament of Insured... Trustee, or successor in Trust, named in the Last Will and Testament of the Insured; provided, however, that if no Trustee is appointed within one year of the Insured s death, payment shall be made to the Insured s estate 6. Other Trust Arrangements... Professional Trust Company, Trustee, or its successor in Trust, under Trust Agreement dated Jan. 1, Corporation... XYZ, Inc., a New York corporation 8. Partnership... ABC Company, a partnership 1. Executor or administrator... Insured s estate Instructions for Signing the Change of Beneficiary Form Who Must Sign: The Change of Beneficiary Form must be signed by the person or persons who, under the terms of the policy, have the right to change the beneficiary. If the previous beneficiary was designated as an irrevocable beneficiary, that irrevocable beneficiary must also sign. How to Sign: Your request cannot be processed without the correct signature(s), date and applicable documentation. If signed by: (a) a corporation, an authorized officer must sign. Be sure to include the title of the officer and the full corporate name. If president no additional requirements If any other officer provide a Board of Directors resolution authorizing the change (b) a partnership with at least two general partners, two authorized general partners must sign with the title general partner after each name (if only one use sole general partner ) and include the full name of the partnership. Also submit a copy of the pages of the partnership agreement showing the authorized partner(s) names and signature(s). (c) a limited liability company, the individual(s) authorized to act must sign. Be sure to include the title of the individual and the company name. Also provide the document (e.g., operating agreement or articles of organization) that defines who is authorized to act for the company. (d) a holder of power of attorney must provide a copy of the power of attorney and include, following his or her signature, the words Attorney-in-fact for (owner s name). If signed with an X mark or in foreign characters, the signature must be witnessed by two witnesses and the address of each witness must be given. Changing a beneficiary will not change the ownership of the policy. The interest of any beneficiary will be subject to the interest of any collateral assignee under a collateral assignment on record with the company. L4237_1212
6 Change of Beneficiary Insured Name Insured Address Policyowner s Name Social Security Number Telephone Number Policy Number Important! 1. Proceeds payable must be expressed as percentages rather than dollar amounts. 2. Please use full given names. Example: Mary E. Doe rather than Mrs. John E. Doe. 3. Forms cannot be accepted which contain corrections or erasures. 4. If more space is needed for additional beneficiaries, please attach a separate sheet of paper or copy of this form. 5. Complete, sign and return this form for each Policy and/or Policy Rider for which you are requesting a change. Mail completed form to: Mutual of Omaha Fax to: ATTN: Policyowner Services Mutual of Omaha Plaza Omaha, NE Primary Beneficiary(ies) Irrevocable Primary Beneficiary(ies): If this Box is checked, the Policy will be endorsed to show that the Primary Beneficiary(ies) named above is/are irrevocable. Future changes to the Policy and/or rider(s), including a change of beneficiary(ies), may not be made by the Policyowner(s)/Trustee(s) without the consent of the Irrevocable Primary Beneficiary(ies) shown above. Contingent Beneficiary(ies) L4237_1212 Please see reverse side
7 Unless otherwise shown above: (a) payment will be shared equally by all Primary Beneficiaries who survive the Insured; if none, by all Contingent Beneficiaries who survive the Insured; (b) the right to change the beneficiary is reserved unless otherwise stated; (c) the word child or children shall include legally adopted children. No changes are binding until received and recorded by the company at its home office. We will record the change(s) and send a confirmation. The company reserves the right to declare this form void and of no effect if it is incomplete or completed in an unsatisfactory manner. As Policyowner, I hereby revoke any previous Beneficiary designation. I request that upon the death of the Insured named above all proceeds of the Policy and/or rider(s) covering the Insured be paid to the beneficiary(ies) as shown above. Signature of Policyowner Date Signature of all current Irrevocable Primary Beneficiary(ies) *If the Policyowner is a corporation or partnership, include (if applicable) documentation indicating authorized signature(s). Signature of Joint Policyowner (if applicable) Date Signature of all current Irrevocable Primary Beneficiary(ies) *If the Policyowner is a corporation or partnership, include (if applicable) documentation indicating authorized signature(s). For Massachusetts residents only: State law requires that a disinterested adult, who is not a party to the Policy, witness any request to change the beneficiary arrangement. X Witness Signature (Massachusetts only) L4237_1212
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