Form Mps 93 – Fill Out and Use This PDF

WILLIAM PENN LIFE INSURANCE COMPANY OF NEW YORK

100 QUENTIN ROOSEVELT BOULEVARD • PO BOX 519 • GARDEN CITY, NEW YORK 11530

MULTIPURPOSE POLICY SERVICE FORM

Use this form to: change address, premium mode, name, beneficiary or owner; request policy certificate, duplicate policy, policy loan or effect release of interest.

INSTRUCTIONS

1.A separate request form must be completed for each policy.

2.Please print or type all information except signatures.

3.If applicable, the term "insured" also means "annuitant", and the term "policy" also means "contract".

REQUIRED SIGNATURES

1.Owner must sign ALL requests.

2.If policy is collaterally assigned, assignee must sign if request number 4, 5, 8, or 9 is made.

3.If beneficiary was designated without right of revocation, beneficiary must sign if request number 7, 8 or 9 is made.

4.If owner resides in a community property state, the spouse of the owner must sign if request number 7, 8 or 9 is made.

5.If owner is a partnership, each partner must sign if request number 8 or 9 is made.

6.If owner is a corporation, only an authorized officer, other than the insured, may sign. A resolution of authorization by the corporation board of directors must be attached to this form if request number 8 is made.

7.If assignee is a corporation, only an authorized officer may sign and the corporate acknowledgement completed if request number 10 is made.

8."Witness Signature" and "Additional Required Signature(s)" in number 11 apply to any and all requests within this form.

Mailing Address of Owner: _______________________________________________________________________________________

1.! ADDRESS CHANGE (Owner only). The "Mailing Address of Owner" indicated above is a change of address. Change policy records and send all future correspondence and notices to the new address.

2.! ADDRESS CHANGE (Other than Owner)

For ! Insured ! Assignee ! Other (specify)_____________________________________________________

New Address: ___________________________________________________________________________________________

3.! MODE OF PREMIUM PAYMENT CHANGE

!Minimum Deposit ! Other____________________________________________________

NOTE: One of the premium due dates of the new mode must be a policy anniversary.

4.! POLICY CERTIFICATE (there is no charge for issuing a policy certificate).

I hereby declare that the above policy was lost or destroyed under the following circumstances:__________________________

______________________________________________________________________________________________________

I request the Company to issue a Policy Certificate in lieu of the above policy. I agree that if the original policy is found, the Policy Certificate will be null and void and will be promptly returned to the Company.

5.! DUPLICATE POLICY (there is a $25.00 fee for issuing a duplicate policy, which must be submitted with this request. All checks must be made payable to William Penn Life Insurance Company of New York).

I hereby declare that the above policy was lost or destroyed under the following circumstances:__________________________

______________________________________________________________________________________________________

I request the Company to issue a duplicate of the above policy numbered the same as the original. I agree that, upon issuance of the duplicate policy, the copy shall stand in the place and instead of the original policy for all purposes; the original policy, if still in being, will be null and void; and if the original is found, it will be promptly returned to the Company. I agree to hold the Company harmless from any claim or expense under the original policy.

6.! NAME CHANGE OR CORRECTION

NOTES: 1. For all name changes, other than by marriage, attach a certified copy of the legal document (such as court order, adoption papers). Change cannot be processed without such proof.

2.If name is that of a corporation, submit certified resolution of the board of directors changing its name and copy of document indicating change officially recorded with state of incorporation.

7.! BENEFICIARY CHANGE - When completed by the Company, this change constitutes an endorsement to your policy.

I hereby revoke all previous beneficiary designations and settlement options for the above policy. The beneficiary designation shall be as shown below. The rights of the beneficiary will be subject to the rights of any assignee of record.

PRINT NAME OF BENEFICIARY(IES), ADDRESS, DATE OF BIRTH AND RELATIONSHIP TO THE INSURED:

Primary:

Contingent:

Unless otherwise provided, the proceeds of the policy are to be paid in one sum. Unless otherwise provided, if two or more beneficiaries are named in a class (Primary or Contingent) all members of the class who survive the insured will SHARE equally in any payment(s) due.

8.! OWNERSHIP CHANGE - ABSOLUTE ASSIGNMENT

For the value received, I hereby give all rights and privileges incident to ownership of the above policy, including the right to surrender for cash value, to:

New Owner: ________________________________________ Social Security Number: _____________________________

Mailing Address: ________________________________________________________________________________________

All future correspondence and notices, unless otherwise specified, will be sent to the "Mailing Address" indicated above. CAUTION: This change of ownership does not change the existing beneficiary designation; the new Owner may change the beneficiary without that person's consent unless designated without right of revocation.

9.! POLICY LOAN AGREEMENT

Make a policy loan: a. ! For full amount

b.! For ______________________ or full amount available (if less)

c.! To pay premium due _____________________ for policy number ______________________

Make check payable to (A or B only): ________________________________________________________________________

Loan Agreement

In consideration of the loan, the undersigned hereby assign, transfer and set over to the Company, its successors and assigns, the said policy and all benefits now due or which may hereafter become due thereon, to secure the repayment of said loan and interest thereon. In consideration of said Company waiving the deposit of said policy with it, its rights shall in no manner whatsoever be prejudiced by such waiver.

10.! RELEASE OF INTEREST

a. By: ! Collateral Assignee ! Beneficiary ! Other (specify) _________________________________________

For the value received, I hereby release all rights, title and interest in the above policy.

b.! SPOUSE/FORMER SPOUSE IN COMMUNITY PROPERTY STATE

I (print full name) _____________________________________________________, spouse/former spouse of the owner of the above policy, hereby release all rights, title and interest which I may have had in this policy now or in the future, by virtue of the Community Property Laws of the State of _________________________________________.

___________________________________________________________________________________________________

11.! BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT: I understand that this request is subject to the provisions and conditions of the above policy and that the Company may request additional information or impose additional requirements. I agree that my signature shall apply to each request which has been checked on this form and further agree that no request will become effective which is not checked. I certify that the above Policy is not pledged or assigned to any other person or corporation, except where stated in the request, that the contract is not in any way pledged as security for moneys advanced or value received, and that no proceedings in bankruptcy are pending.

__________________________________________________

Additional Required Signature, If Any

(Apply to any item in this form where required)

CORPORATE ACKNOWLEDGEMENT

COUNTY OF _________________________________________

ss:

STATE OF ___________________________________________

On the _______________________________________ day of ________________________________, 19______, before me personally came

_____________________________________________________________, who being by me duly sworn, did depose and say that he resides in

_____________________________________________________; that he is the ______________________________________________ of

_____________________________________, the corporation described in and which executed this release; that he knows the seal of said

corporation;thatthesealaffixedtosaidassignmentissuchcorporateseal;thatitwassoaffixedbyorderoftheBoardofDirectorsofsaidcorporation and that he signed his name thereto by like order.

FOR COMPANY USE ONLY

The above request for change is acknowledged and has been completed by the Company at its Home Office. This acknowledgement applies only to the policy specified in the form. Presentation of the policy for completion of this change has been waived.