Get Va108 2010-2024

Jefferson National Life Insurance Company Regular Delivery P. O. Box 36750 Louisville KY 40233 Overnight 9920 Corporate Campus Drive Louisville KY 40223 P 866. 667. 0561 F 866. 667. 0563 CHANGE BENEFICIARY REQUEST FORM OWNER/CONTRACT INFORMATION Contract Number Name of Owner Owner SSN/EIN Owner Address City State Owner Email Owner Phone Number Owner Date of Birth Zip Name of Joint Owner if applicable Joint Owner SSN/EIN Name of Annuitant if different from owner Annuitant SSN/EIN Annuitant Address NEW BENEFICIARY DESIGNATION Subject to the provision of the contract settlement of the Contract Value upon the death of the Annuitant shall be payable to the beneficiaries listed below. Jefferson National Life Insurance Company Regular Delivery P. O. Box 36750 Louisville KY 40233 Overnight 9920 Corporate Campus Drive Louisville KY 40223 P 866. 667. 0561 F 866. 667. 0563 CHANGE BENEFICIARY REQUEST FORM OWNER/CONTRACT INFORMATION Contract Number Name of Owner Owner SSN/EIN Owner Address City State Owner Email Owner Phone Number Owner Date of Birth Zip Name of Joint Owner if applicable Joint Owner SSN/EIN Name of Annuitant if different from owner Annuitant SSN/EIN Annuitant Address NEW BENEFICIARY DESIGNATION Subject to the provision of the contract settlement of the Contract Value upon the death of the Annuitant shall be payable to the beneficiaries listed below. All previous beneficiary designations are hereby revoked* PRIMARY BENEFICIARY S FULL NAME RELATIONSHIP SSN DATE OF BIRTH OF PROCEEDS Must equal 100 CONTINGENT BENEFICIARY S FULL NAME If none of the above are living or if this designation is ineffective proceeds will be paid to the insured s estate. If a Trust is named as the Beneficiary a certified copy of the Trust is required* The Company is free from liability in relying on a statement about birth death marriage names and addresses and other facts concerning all beneficiaries from any other one. Unless otherwise stated the survivors of a beneficiary class share equal amounts of the proceeds. OWNER ACCEPTANCE Form must be completed and signed by the person or persons who under the terms of the contract have the rights of ownership* This form must accompany the Assignee s paperwork. Owner Signature Date Joint Owner/Annuitant/Spouse s Community Property Signature Previous Irrevocable Beneficiary Signature if applicable X Unless the Company has been notified of a community property interest in this contract the Company shall be entitled to rely on its good faith belief that no such interest exists and assumes no responsibility for inquiry. The insured and/or policy-owner signing this form agrees to indemnify and hold the Company harmless from the consequences of accepting this transaction* Community property states AZ CA ID LA NV NM TX WA WI. NO AGENT IS AUTHORIZED TO ALTER THE TERMS OF THE CONTRACT OR BIND THE COMPANY. VA108 Page 1 of 1 05/10. 667. 0561 F 866. 667. 0563 CHANGE BENEFICIARY REQUEST FORM OWNER/CONTRACT INFORMATION Contract Number Name of Owner Owner SSN/EIN Owner Address City State Owner Email Owner Phone Number Owner Date of Birth Zip Name of Joint Owner if applicable Joint Owner SSN/EIN Name of Annuitant if different from owner Annuitant SSN/EIN Annuitant Address NEW BENEFICIARY DESIGNATION Subject to the provision of the contract settlement of the Contract Value upon the death of the Annuitant shall be payable to the beneficiaries listed below. All previous beneficiary designations are hereby revoked* PRIMARY BENEFICIARY S FULL NAME RELATIONSHIP SSN DATE OF BIRTH OF PROCEEDS Must equal 100 CONTINGENT BENEFICIARY S FULL NAME If none of the above are living or if this designation is ineffective proceeds will be paid to the insured s estate. .