Form G121 PDF Details

Form G121 is a form used to request or provide information about a deceased individual. It is often used to provide the necessary information for death and burial permits. The form can be completed by anyone with knowledge of the decedent, such as a family member or close friend. Completing the form accurately is important, as it will help ensure that the decedent's estate is handled correctly.

This quick report will help you figure out the time it'll take you to fill out form g121, the number of pages it has, and a handful of other specific details about the PDF.

QuestionAnswer
Form NameForm G121
Form Length2 pages
Fillable?Yes
Fillable fields54
Avg. time to fill out11 min 22 sec
Other nameswestern holder request, Ogden, NamePlease, POLICYHOLDER

Form Preview Example

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 Assignee 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 Assignee 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 Ste

The software will need you to fill out the Address, City, State, Zip Address, City, State, Zip Name, Change, of Insured, Owner, From, Former, Name, Please, Print To, New, Name, Please, Print Reason, for, change Ownership, Change Print, Name, of, New, Owner So, cSec, of, New, Owner Signature, of, New, Owner and Address, of, New, Owner part.

stage 2 to finishing Ste

Note the fundamental details as you are within the POLICY, NUMBER Irrevocable, Assignment, of, Benefits Mortuary, Name Would, you, like, to, take, a, policy, loan Issue, check, for or, maximum, amount, available Make, check, payable, to, policy, owner and Make, check, payable, to field.

Ste POLICYNUMBER, IrrevocableAssignmentofBenefits, MortuaryName, Wouldyouliketotakeapolicyloan, Issuecheckfor, ormaximumamountavailable, Makecheckpayabletopolicyowner, and Makecheckpayableto fields to fill out

It is essential to identify the rights and responsibilities of all parties in part Make, check, payable, to, Policy, owner Make, check, payable, to SIGNATURES, Witness, Non, Family, Member and Date.

MakecheckpayabletoPolicyowner, Makecheckpayableto, SIGNATURES, WitnessNonFamilyMember, and Date in Ste

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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