Midland National PDF Details

Midland National has created a new form, which provides easier access to information for advisors and policyholders. The new form consolidates account and policy data into one location. This makes it simpler for customers to understand their policies and for advisors to provide service. The Midland National Form is also designed to improve customer service interactions with the company. Advisors now have direct access to account data and documents, making it easier to provide recommendations and support. Customers can also quickly find the information they need on their policies, as well as download or print copies of documents. Overall, the Midland National Form is an impressive step forward in terms of enhancing customer service. Advisors and customers alike will appreciate its streamlined design and ease of use.

If you'd like to first determine how much time you need to complete the midland national and the number of pages it's got, here is some detailed information that co

Form NameMidland National
Form Length2 pages
Fillable fields55
Avg. time to fill out11 min 34 sec
Other namesmidland national annuity forms, midland national life insurance forms, midland 6773y, midland life insurance beneficiary form

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Savings Account
Checking Account

Clear Form


To be completed for partial surrenders. For questions, please contact the Midland National Customer Service Department. Phone: 877-586-0244 Fax: 877-586-0249

I/We hereby acknowledge that the information provided herein is to the best of our knowledge true and accurate. I/We also acknowledge that this form must be fully completed, and failure to complete any portion of this form may delay the processing of this request. The completion of this form is necessary to satisfy the Written Notice Requirement as defined in Section 1 of your annuity contract.

I. Account Information

Contract Number:

Contract Owner:

First NameMI Last Name

Joint Owner's Name: (If applicable)

First Name




Last Name







































































Trust or Corporation Name: (if owner is a Trust or a Corporation)

Owner's Mailing Address:

Street Address

Phone Number


Address (cont.)





Zip Code


II. Partial Surrender Information (Please check one)

10% Penalty-Free Withdrawal

Other $

III. Method of Payment

A check will be sent out regular mail unless indicated differently



(Please specify net amount of check)

Alternate payment options:


Please bill my overnight account:


Account #:

Electronic Funds Transfer Authorization - I authorize Midland National and the financial institution listed on the following page to automatically deposit withdrawals into:

*The funds will generally be available three business days after the payment date.

*This option may not be available for all products.

(Continued on back)











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Notary Signature:
(A notary signature is needed for all surrender charges greater than $10,000)
Spousal Signature:Not Married Date:
(Spousal signature applicable only if the contract was issued in or the contract owner resides in: AZ, CA, ID, LA, NM, NV, TX, WA, or WI)
Joint Owner Signature/Assignee:
Contract Owner Signature/Assignee:
Certification - Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and;
2. I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and;
3. I am a U.S. person.
(Must be completed)

III. Method of Payment (Continued)

Should an inappropriate deposit be made, the financial institution is authorized to make a debit entry to my account and return to Midland National the corrected amount. This authorization will remain in effect until I have cancelled it in writing.

Financial Institution's Name

Street Address

Address (cont.)

























Zip Code






























































































Account Number at Financial Institution

Routing Number (ABA#)






































































































A voided check is required for verification of all financial institution information.

IV. Election of Withholding

You must indicate if Federal/State income taxes should be withheld from your payment by signing and dating this election form and returning it to Midland National. State taxes will be withheld only if required by your state. Even if you elect not to have Federal/State income taxes withheld, you are liable for Federal/State income taxes on the taxable portion of your benefits. You may also be subject to tax penalties under the Estimated Tax Payment rules if your payments of estimated tax and withholding, if any, are not adequate. If no election is made, 10% Federal

income tax will be withheld.

Check One:

I do not want Federal/State income taxes withheld from my payment.

I do want Federal/State income taxes withheld from my payment.





Social Security Number








Employer Identification Number






















































































Social Security Number








Employer Identification Number














































































































































































2 0 2 6 7 7 3 Y

REV 03/05

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Please enter the following details to create the midland national life insurance company beneficiary change request PDF:

step 1 to completing midland national life insurance forms

Put down the information in the Owners, Mailing, Address Street, Address Address, cont City, Phone, Number State, Zip, Code II, Partial, Surrender, Information Please, check, one Penalty, Free, Withdrawal Other, Please, specify, net, amount, of, check III, Method, of, Payment Alternate, payment, options and Please, bill, my, overnight, account area.

step 2 to finishing midland national life insurance forms

The software will request you to provide particular vital details to automatically complete the segment Checking, Account Savings, Account Continued, on, back and REV.

Completing midland national life insurance forms part 3

The Street, Address Address, cont City, State, Zip, Code Account, Number, at, Financial, Institution Routing, Number, ABA Federal, and State section is the place where all sides can put their rights and obligations.

Finishing midland national life insurance forms step 4

Prepare the form by reviewing the following sections: Employer, Identification, Number Employer, Identification, Number Contract, Owner, Signature, Assign, ee Joint, Owner, Signature, Assign, ee Spousal, Signature Date, Date, Not, Married Date, Notary, Signature Date, and REV.

part 5 to completing midland national life insurance forms

Step 3: Once you hit the Done button, your completed document is readily transferable to each of your devices. Or alternatively, you will be able to deliver it by means of mail.

Step 4: Prepare around two or three copies of your file to keep clear of all of the possible concerns.

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