Form G121 PDF Details

The G121 form is a comprehensive document issued by the Great Western Insurance Company, catering to various policyholder service requests that can significantly impact the management and distribution of policy benefits. This form encompasses several key alterations a policyholder might need to make, including changing the designated funeral home, updating beneficiary information, adjusting personal details like name changes, transferring ownership of the policy, and even handling more complex financial decisions such as taking out a policy loan or surrendering the policy altogether. It also allows for the irrevocable assignment of benefits, usually in connection with pre-planned funeral arrangements, ensuring that policy proceeds are directly transferred to a specified mortuary. Among its other provisions, the form facilitates updating contact information and introduces an open section for additional requests not explicitly listed, ensuring policyholders have a clear path to making essential updates. Completing the G121 form is a step towards ensuring that one's policy reflects current wishes and circumstances, with the effect of changes being carefully recorded at the company's headquarters in Ogden, Utah.

QuestionAnswer
Form NameForm G121
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesG121, great western insurance company g100gwf00249, NamePlease, Ste

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G R E AT WESTERN

I N S U R A N C E C O M P A N Y

3434 Washington Blvd Ste. 100. • Ogden, Utah 84401 • 801-689-1401 Voice • 801-689-1391 Fax

POLICYHOLDERSERVICEREQUEST

OWNER (if other than insured)

INSURED

POLICYNUMBER (one policy only)

◆CurrentPolicyownerMustSignandDateTheReverseSide0fThisForm.

1. Funeral Home Changes:

❑ Remove

❑ Change

OldFuneralHome

Name

NewFuneralHome

Name

Phone Number

Phone Number

Address

Address

City, State, Zip

City, State, Zip

AddBeneficiary

❑ Primary

❑ Contingent

RemoveBeneficiary

❑ Primary

❑ Contingent

 

 

 

 

 

 

 

 

Name

 

 

Age

Name

 

 

Age

 

 

 

 

 

 

 

 

Social Security Number

 

 

 

Social Security Number

 

 

 

 

 

 

 

 

 

 

Relationship to Insured

 

Phone Number

Relationship to Insured

 

Phone Number

 

 

 

 

 

 

 

 

 

Address

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

City, State, Zip

 

 

 

City, State, Zip

 

 

 

 

 

 

 

 

 

 

 

Proceeds will be paid in equal shares to all primary beneficiaries who survive the insured, but if none survive the insured, proceeds will be paid in equal shares to all contingent beneficiaries who are living. This changecancels any previous beneficiary designation or settlement agreement.

2.Name Change of:

** Note:This change will NOT transferownershiprights **

❑ Insured

❑ Owner

 

 

 

___________________________________________________

__________________________________________________

From (Former Name–Please Print)

 

 

To (New Name–Please Print)

Reason for change: ___________________________________________________________________________________________

3.OwnershipChange:

 

 

 

 

Newownersignhere;currentownersignreversesideofform.

 

 

_________________________________

___________________________________ _________________________________

Print Name of New Owner

Soc Sec # of New Owner

Signature of New Owner

____________________________________________________________

__________________________________________

 

Address of New Owner

 

Witness(Non-FamilyMember)

FormG121(0800)

 

(OVER)

 

 

POLICYNUMBER _____________________

4.IrrevocableAssignment of Benefits

As the owner of the life insurance referred to above, I hereby irrevocably assign and transferall the policy benefits and proceeds of such policy to _________________________________________________________________________________________

Mortuary Name

I make this irrevocable assignment of benefits in connection with a pre-paid funeral plan which I have entered into, and I under- stand fully the effect of this assignment and transfer.

Designation of a beneficiary by me before or after the date of this assignment is subjectto this assignment and transfer.

Itismyintention,asownerofthepolicyreferredtoabove,tocontinuetopaythepremiumsandtoretainownershipofthepolicy.

5.Would you like to take a policy loan?

Issue check for ❑$ _______________

or ❑ maximum amount available.

❑Make check payable to policyowner

❑Make check payable to _______________________________________________________________________________

LoanAgreement InconsiderationoftheloanmadebyGreatWesternInsuranceCompany,Iassignthepolicytothecompanyassolesecurityfor therepaymentoftheloanwithinterestsubjecttotheprovisionsofthepolicy. IcertifythatnoBankruptcyProceedings,attach- ment,taxorotherlienorclaimisnowpendingagainstmeandthatthepolicyhasnotbeenpreviouslyassigned.

6.Do you need to surrenderyourpolicy? Please submit policy. If policy is lost, mark this box ❑

Thecashsurrendervalueisrequestedandwillbeacceptedinfullpaymentandreleaseofallclaimsunderthepolicy.Thesur- renderwillbeeffectivewhenthisrequestisreceivedbytheCompanyatitsOfficeinOgden,Utah.

❑MakecheckpayabletoPolicyowner

❑Makecheckpayableto __________________________________________________________________________________

Icertifythatnobankruptcyproceedings,attachment,taxorotherlienorclaimisnowpendingagainstme,andthatthepolicyhas

notbeenpreviouslyassigned.

7. Address/Telephone Numberchange forcurrent policyowner:

_________________________________________________________________________________________________________

8.Additional Request (Any OtherChanges Not ListedAbove)

________________________________________________________________________________________________________

SIGNATURES

I/weagreethatmy/oursignature(s)belowshallapplytoeachrequestwhichhasbeencompletedoneithersideofthisform

_____________________________________________

_______________

___________________________________________

Witness(Non-FamilyMember)

Date

CurrentPolicyowner(ifownedbyacompany,showtitle)

_____________________________________________

 

___________________________________________

IrrevocableBeneficiary/AssigneeSignature

 

Spouse’sSignaturerequiredinaCommunityPropertyState

 

 

(Ifnone,stateNONE–Formwillnot beacceptedunlesscompleted)

 

 

 

 

RECORDEDATTHEHOMEOFFICEON _____________________

BY________________________________________________________________________

How to Edit Form G121 Online for Free

Creating documents along with our PDF editor is more straightforward compared to nearly anything. To modify NamePlease the form, there isn't anything for you to do - just adhere to the actions below:

Step 1: Choose the "Get Form Now" button to begin the process.

Step 2: Once you have accessed your NamePlease edit page, you'll see all actions you may undertake concerning your file at the top menu.

For every single area, add the details required by the software.

portion of blanks in how to update address for great western insurance company

The software will need you to fill out the Social Security Number, Social Security Number, Relationship to Insured, Phone Number, Relationship to Insured, Phone Number, Address, City State Zip, Address, City State Zip, Proceeds will be paid in equal, Name Change of, Note This change will NOT, Insured, and Owner part.

stage 2 to finishing how to update address for great western insurance company

Note the fundamental details as you are within the New owner sign here current owner, Print Name of New Owner, Soc Sec of New Owner, Signature of New Owner, Address of New Owner, Witness NonFamily Member, Form G, and OVER field.

how to update address for great western insurance company New owner sign here current owner, Print Name of New Owner, Soc Sec of New Owner, Signature of New Owner, Address of New Owner, Witness NonFamily Member, Form G, and OVER fields to fill out

It is essential to identify the rights and responsibilities of all parties in part POLICY NUMBER, Irrevocable Assignment of Benefits, As the owner of the life insurance, Mortuary Name, I make this irrevocable assignment, Designation of a beneficiary by me, It is my intention as owner of the, Would you like to take a policy, Issue check for, or maximum amount available, Make check payable to policyowner, Loan Agreement In consideration of, and Do you need to surrender your.

POLICY NUMBER, Irrevocable Assignment of Benefits, As the owner of the life insurance, Mortuary Name, I make this irrevocable assignment, Designation of a beneficiary by me, It is my intention as owner of the, Would you like to take a policy, Issue check for, or maximum amount available, Make check payable to policyowner, Loan Agreement In consideration of, and Do you need to surrender your in how to update address for great western insurance company

End by reviewing all these sections and filling them in accordingly: render will be effective when this, Make check payable to Policyowner, AddressTelephone Number change, Additional Request Any Other, SIGNATURES, Iwe agree that myour signatures, Witness NonFamily Member, Date, Current Policyowner if owned by a, Irrevocable BeneficiaryAssignee, and Spouses Signature required in a.

part 5 to entering details in how to update address for great western insurance company

Step 3: Select the Done button to save the form. Now it is readily available for upload to your electronic device.

Step 4: In order to avoid potential future problems, take the time to hold a minimum of several copies of each and every document.

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