Form Fgli 0177 PDF Details

Form FGLI 0177 is an informational form used to report workers' compensation benefits. This form is completed by the claimant and submitted to their insurance company. The purpose of this form is to provide detailed information about the workers' compensation claim, including the nature of the injury, the date of the injury, and the estimated duration of the disability. By completing Form FGLI 0177, claimants can ensure that their insurance company has all the information they need to process their claim.

QuestionAnswer
Form NameForm Fgli 0177
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesOM Ownership.Benef iciary.Annuitan t Change Request fidelity and guaranty beneficiary change form

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Transfer of Ownership/Change of Beneficiary/Change of Annuitant

I N S U R E R

OM Financial Life Insurance Company

I N S U R E D

Contract No.

Insured / Annuitant

P A R T A : T R A N S F E R O F O W N E R S H I P

The undersigned hereby transfers ownership of said, together with all rights and privileges incident thereto, including the right to receive all amounts payable during the insured’s lifetime to:

Name

New owner’s Social Security Number

Address

City

 

 

Joint owner (if any)

 

 

 

Joint owner’s Social Security Number

 

 

 

Address

City

Relationship of new owner to insured

New owner’s date of birth

StateZip

Relationship of joint owner to insured

Joint owner’s date of birth

State

Zip

and to the executors, administrators, successors or assigns of the transferee, except that the naming of joint owners herein will create right of survivorship unless otherwise designated. If the subject contract is a juvenile contract (Issue age 0-14) the rights hereby transferred will be limited as provided by the contract provisions entitled Ownership and Transfer of such contract. Subject to the terms and conditions of the contract, this transfer shall take effect as of the date hereon. This transfer shall revoke any previous designation of owner or contingent owner or any transfer of ownership and effective date which has not been reached but shall not revoke any designation of beneficiary. Under the penalties of perjury, I certify that the social security number reflected above is correct, and I have not been notified by IRS that I am subject to backup withholding. (If you have been advised you are subject to back-up withholding you must indicate so here: )

P A R T B : C H A N G E O F B E N E F I C I A R Y

Effective immediately prior to the transfer of ownership provided in Part A above, the beneficiary designation under said policy is hereby changed as follows: (Please print name in full giving relationship to insured.)

Primary Beneficiary

 

Relationship to Insured

 

Social Security No.

 

 

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

 

 

 

City

 

 

 

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

Contingent Beneficiary

 

Relationship to Insured

 

Social Security No.

 

 

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

 

 

 

City

 

 

 

State

 

Zip

OM Financial Life Insurance Company Baltimore, MD

FGLI 0177 (02-2004)

Original-Company Copy- Applicant Copy-Agent

Rev. 01-2007

Transfer of Ownership/Change Beneficiary/Change of Annuitant - Page 2

P A R T C : C H A N G E O F A N N U I T A N T

Note: This change is subject to the annuity contract provisions and is not available on all annuity contracts. Please refer to your annuity contract or contact your insurance representative.

The Annuitant cannot be a non-natural person.

I hereby designate the Annuitant of the contract designated herein to:

Annuitant

 

Social Security No.

 

Date of Birth*

 

 

 

Daytime Phone No.

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

 

 

 

City

 

 

 

State

 

Zip

Reason for change:

*Proof of age is required for annuity types 2 through 7.

I M P O R T A N T N O T I C E

A separate form should be completed for each contract and forwarded to the Home Office. For transfer of ownership without change of beneficiary or change of annuitant, complete Part A only. Otherwise, complete applicable areas to be changed. See rules below regarding signature and other requirements if policy is owned by other than an individual, and for specimen beneficiary designations.

This transaction may be a taxable and reportable event. The Owner(s) is requesting this change pursuant to his/her own specific situation. To this end, the Owner(s) consulted with a financial or tax advisor and acknowledges that he/she is directing the applicable insurance company to effect the change. In addition, the Current and New contract owner(s), participant(s) plan administrator, if applicable, each agree to hold harmless and indemnify OMFN to any and all claims or demands which may be made by reason of the changes so made.

Dated at ____________________________________ this ____________ day of

 

,

 

.

 

 

 

 

 

Signature of Current Owner/Participant

Date

Signature of Current Joint Owner/Participant

Date

(If Corporation, signature and title of authorized officer.)

 

 

 

 

 

 

 

 

 

 

 

Signature of New Owner/Participant

Date

Signature of New Joint Owner/Participant

Date

(If corporation, signature and title of authorized officer.)

 

 

 

 

 

 

 

 

 

 

 

 

Witness to all signatures

 

 

Assignee or Irrevocable Beneficiary

 

 

Acknowledged and accepted by OM Financial Life Insurance Company:

 

Date

 

By

 

 

 

 

 

 

S I G N A T U R E R E Q U I R E M E N T S

If the transfer or exchange is executed by a corporation, a signature from each of two individual officers, authorized by the corporation to effect the assignment on behalf of the corporation, is required. If the above is executed by a partnership, all partners must sign and be designated as a partner. If the policy is owned by a pension or profit-sharing trust, the above should be executed by the trustee(s) empowered under the trust to make such change.

S P E C I M E N B E N E F I C I A R Y D E S I G N A T I O N S

Insured’s Estate -- “Executors or Administrators of the Insured’s Estate”

One Primary and One Contingent – “Mary J. Doe, Insured’s Wife, if living at Insured’s death, otherwise equally to such lawful children of Insured (or substitute – ‘to such children of Insured by said wife’), as may then be living.”

Delayed Payment (Common Disaster) Clause – “Mary J. Doe, Insured’s wife, if living on the 30th day after the death of the Insured; otherwise . . . “

Corporation – “The Brown Paper Company, Inc., a Maryland Corporation, its successors or assigns.”

Partnership – “John Doe and Sons, a partnership consisting of John Doe, James Doe, and Robert Doe, its successors or assigns.”

Corporate Trustee – “First National Bank, Baltimore, Maryland, trustee, or its successors in trust, under trust agreement dated February 15, 1989.”

Individual Trustee – “John J. Jones Insurance Trust naming Mary Smith as trustee under trust agreement dated February 15, 1989.”

OM Financial Life Insurance Company Baltimore, MD

FGLI 0177 (02-2004)

Original-Company Copy- Applicant Copy-Agent

Rev. 01-2007