Service Forms
We want to make it easy to manage your policy
Tell us more about you so we can provide the right forms for your policy.
Note: Entering your policy/contract number helps find the most relevant forms results and can avoid delays in your service experience. Please take the time to locate your account information before proceeding.
Most Commonly Requested Forms
Update the address we have on file with your policy. When filling out the form, be sure to include the name of annuitant or insured and the contract/policy number. Choose whether you are changing the address for the owner, annuitant, insured, assignee, or a recipient of a duplicate notice. Provide the name and contact information of the policy owner. This form requires the signature of the owner and joint owner (if any).
Update the name of the annuitant we have on file with your policy.
Use this form to make changes to your Federal or State tax withholding elections.
Authorize release of medical information to Nassau. This form may be used to authorize release of medical information to Nassau. If you live in Kansas, Massachusetts, Maine, Minnesota, New Mexico or Vermont, be sure to select the form specific to your state.
Change the beneficiary designation on any of of your life or annuity policies.
Automatically deposit checks for premium payment, premium deposit fund, or loan repayment.
Request that medical records used during the underwriting process be released to the individual whose information is to be released.
Update the name we have on file with your policy.
Designate individual(s) as new owner(s).
Designate which rider(s) you wish to surrender.
Variable Product Forms
Readjust investment allocations by shifting money among subaccounts.
Select an asset rebalancing or a dollar cost averaging investment program for your variable annuity.
Optional Investment Programs for Variable Annuities - OL4061
Use this form to select the subaccount(s) for your premium or loan payment allocation, or choose an asset allocation program for all annuities except Spectrum Edge+
- California residents cannot select subaccounts that are denoted not available in California.
- The Guaranteed Interest Account is not available for the Phoenix Income Choice product.
- You may select MVA as a subaccount option except for the following states: Maine, Maryland New Jersey, New York, Oregon, Pennsylvania, Texas and Washington.
- MVA is not available for the Phoenix Income Choice product.
Use this form to select the subaccount(s) for your premium or loan payment allocation.
Variable Universal Life Authorization for Payments, Transfers & Allocations - OL1320I
Agent and Broker Forms
Transfer responsibility for products to another agent or to another broker-dealer.
Inforce Underwriting Forms
Apply for non-smoker rates or non-smoker and neversmoke risk classification.
Apply for a change to an existing policy that requires underwriting for items like a change in lifestyle.
Applications for a Policy Change Fully Underwritten in AK - OL4755AK
Applications for a Policy Change Fully Underwritten in AZ - OL4755AZ
Applications for a Policy Change Fully Underwritten in CA - OL4755CA
Applications for a Policy Change Fully Underwritten in CT - OL4755CT
Applications for a Policy Change Fully Underwritten in FL - OL4755FL
Applications for a Policy Change Fully Underwritten in GA - OL4755GA
Applications for a Policy Change Fully Underwritten in HI - OL4755HI
Applications for a Policy Change Fully Underwritten in IN - OL4755IN
Applications for a Policy Change Fully Underwritten in MA - OL4755MA
Applications for a Policy Change Fully Underwritten in MD - OL4755MD
Applications for a Policy Change Fully Underwritten in ME - OL4755ME
Applications for a Policy Change Fully Underwritten in MN - OL4755MN
Applications for a Policy Change Fully Underwritten in MO - OL4755MO
Applications for a Policy Change Fully Underwritten in MT - OL4755MT
Applications for a Policy Change Fully Underwritten in NC - OL4755NC
Applications for a Policy Change Fully Underwritten in NE - OL4755NE
Applications for a Policy Change Fully Underwritten in NH - OL4755NH
Applications for a Policy Change Fully Underwritten in NM - OL4755NM
Applications for a Policy Change Fully Underwritten in NY - OL4755NY
Applications for a Policy Change Fully Underwritten in OH - OL4755OH
Applications for a Policy Change Fully Underwritten in OK - OL4755OK
Applications for a Policy Change Fully Underwritten in OR - OL4755OR
Applications for a Policy Change Fully Underwritten in PA - OL4755PA
Applications for a Policy Change Fully Underwritten in PR - OL4755PR
Applications for a Policy Change Fully Underwritten in SC - OL4755SC
Applications for a Policy Change Fully Underwritten in TX - OL4755TX
Applications for a Policy Change Fully Underwritten in UT - OL4755UT
Applications for a Policy Change Fully Underwritten in VA - OL4755VA
Applications for a Policy Change Fully Underwritten in VT - OL4755VT
Applications for a Policy Change Fully Underwritten in WA - OL4755WA
Applications for a Policy Change Fully Underwritten in WI - OL4755WI
Applications for a Policy Change Fully Underwritten in all other states - OL4755
Convert part or all of an eligible term life insurance policy to a permanent policy
Term Conversion Application in AK - OL4776AK
Term Conversion Application in CA - OL4776CA
Term Conversion Application in FL - OL4776FL
Term Conversion Application in MA - OL4776MA
Term Conversion Application in ME - OL4776ME
Term Conversion Application in NY - OL4776NY
Term Conversion Application for Use in CO, DE, KS, IL, MI, MO, NV, NM, OR, UT, VA, WY - OL4776ICC
Non-Individual Owner Forms
Designate a Non-Individual as new owner and beneficiary.
Designate a trust as new owner and beneficiary.
Certify the existence of a trust, as well as current trustees and/or successors.
Certification and Acknowledgement of Trust Agreement - OL4132A
Provide required details about the nature of the trust.
Certify that an individual is an elected and presently acting officer of entity, such as a corporation.
Authorize partners to sign on behalf of partnership that owns a policy for all matters related to the policy.
Relinquish the right, title and interest of the assignee to Nassau Life Insurance Company for a specific policy on the life of an insured individual
Assign your life insurance policy as collateral for a loan.
Request split-dollar administrative services: preparing collateral assignment or endorsement, or reporting the annual economic benefit.
Other Forms
File your required minimum distribution (RMD) election.
Give Nassau authority to share policy information with another party.
Disclosure Authorization for Release of Policy/Contract Information - HO5074A
Apply dividends to pay the balance of premiums becoming due by release of paid-up additions.
Request history of all policy account transactions for a specified period of time
Request a new contract if the original has been lost, misplaced or destroyed.
Request a change to information or instructions on a policy
Change a premium-paying policy to a paid-up status.
Restore a lapsed policy to active status.
Reinstatement Application in AK - OL4374AK
Reinstatement Application in AZ- OL4374AZ
Reinstatement Application in CA - OL4374CA
Reinstatement Application in CT - OL4374CT
Reinstatement Application in FL - OL4374FL
Reinstatement Application in GA - OL4374GA
Reinstatement Application in HI - OL4374HI
Reinstatement Application in IN - OL4374IN
Reinstatement Application in MA - OL4374MA
Reinstatement Application in MD - OL4374MD
Reinstatement Application in ME - OL4374ME
Reinstatement Application in MI - OL4374MI
Reinstatement Application in MN - OL4374MN
Reinstatement Application in MO - OL4374MO
Reinstatement Application in NC - OL4374NC
Reinstatement Application in NE - OL4374NE
Reinstatement Application in NJ - OL4374NJ
Reinstatement Application in NM - OL4374NM
Reinstatement Application in NY - OL4374NY
Reinstatement Application in OH - OL4374OH
Reinstatement Application in OK - OL4374OK
Reinstatement Application in OR - OL4374OR
Reinstatement Application in PA - OL4374PA
Reinstatement Application in PR - OL4374PR
Reinstatement Application in SC - OL4374SC
Reinstatement Application in TX - OL4374TX
Reinstatement Application in UT - OL4374UT
Reinstatement Application in VA - OL4374VA
Reinstatement Application in VT - OL4374VT
Reinstatement Application in WA - OL4374WA
Most Commonly Requested Forms
Update the address we have on file with your policy. When filling out the form, be sure to include the name of annuitant or insured and the contract/policy number. Choose whether you are changing the address for the owner, annuitant, insured, assignee, or a recipient of a duplicate notice. Provide the name and contact information of the policy owner. This form requires the signature of the owner and joint owner (if any).
Use this form to make changes to your Federal or State tax withholding elections.
Authorize release of medical information to Phoenix. This form may be used to authorize release of medical information to Phoenix. If you live in Kansas, Massachusetts, Maine, Minnesota, New Mexico or Vermont, be sure to select the form specific to your state.
Change the beneficiary designation on any of of your life or annuity policies.
Automatically deposit checks for premium payment, premium deposit fund, or loan repayment.
Request that medical records used during the underwriting process be released to the individual whose information is to be released.
Update the name we have on file with your policy.
Designate individual(s) as new owner(s).
Agent and Broker Forms
Transfer responsibility for products to another agent or to another broker-dealer.
Inforce Underwriting Forms
Apply for non-smoker rates or non-smoker and neversmoke risk classification.
Apply for a change to an existing policy that requires underwriting for items like a change in lifestyle.
Applications for a Policy Change Fully Underwritten in AK - OL4755AK
Applications for a Policy Change Fully Underwritten in AZ - OL4755AZ
Applications for a Policy Change Fully Underwritten in CA - OL4755CA
Applications for a Policy Change Fully Underwritten in CT - OL4755CT
Applications for a Policy Change Fully Underwritten in FL - OL4755FL
Applications for a Policy Change Fully Underwritten in GA - OL4755GA
Applications for a Policy Change Fully Underwritten in HI - OL4755HI
Applications for a Policy Change Fully Underwritten in IN - OL4755IN
Applications for a Policy Change Fully Underwritten in MA - OL4755MA
Applications for a Policy Change Fully Underwritten in MD - OL4755MD
Applications for a Policy Change Fully Underwritten in ME - OL4755ME
Applications for a Policy Change Fully Underwritten in MN - OL4755MN
Applications for a Policy Change Fully Underwritten in MO - OL4755MO
Applications for a Policy Change Fully Underwritten in MT - OL4755MT
Applications for a Policy Change Fully Underwritten in NC - OL4755NC
Applications for a Policy Change Fully Underwritten in NE - OL4755NE
Applications for a Policy Change Fully Underwritten in NH - OL4755NH
Applications for a Policy Change Fully Underwritten in NM - OL4755NM
Applications for a Policy Change Fully Underwritten in NY - OL4755NY
Applications for a Policy Change Fully Underwritten in OH - OL4755OH
Applications for a Policy Change Fully Underwritten in OK - OL4755OK
Applications for a Policy Change Fully Underwritten in OR - OL4755OR
Applications for a Policy Change Fully Underwritten in PA - OL4755PA
Applications for a Policy Change Fully Underwritten in PR - OL4755PR
Applications for a Policy Change Fully Underwritten in SC - OL4755SC
Applications for a Policy Change Fully Underwritten in TX - OL4755TX
Applications for a Policy Change Fully Underwritten in UT - OL4755UT
Applications for a Policy Change Fully Underwritten in VA - OL4755VA
Applications for a Policy Change Fully Underwritten in VT - OL4755VT
Applications for a Policy Change Fully Underwritten in WA - OL4755WA
Applications for a Policy Change Fully Underwritten in WI - OL4755WI
Applications for a Policy Change Fully Underwritten in all other states - OL4755
Convert part or all of an eligible term life insurance policy to a permanent policy
Term Conversion Application in AK - OL4776AK
Term Conversion Application in CA - OL4776CA
Term Conversion Application in FL - OL4776FL
Term Conversion Application in MA - OL4776MA
Term Conversion Application in ME - OL4776ME
Non-Individual Owner Forms
Designate a Non-Individual as new owner and beneficiary.
Designate a trust as new owner and beneficiary.
Certify the existence of a trust, as well as current trustees and/or successors.
Certification and Acknowledgement of Trust Agreement - OL4132A
Authorize partners to sign on behalf of partnership that owns a policy for all matters related to the policy.
Relinquish the right, title and interest of the assignee to Phoenix Life Insurance Company for a specific policy on the life of an insured individual
Other Forms
Give Phoenix authority to share policy information with another party.
Disclosure Authorization for Release of Policy/Contract Information - HO5074A
Request a new contract if the original has been lost, misplaced or destroyed.
Request a change to information or instructions on a policy
Restore a lapsed policy to active status.
Reinstatement Application in AK - OL4374AK
Reinstatement Application in AZ- OL4374AZ
Reinstatement Application in CA - OL4374CA
Reinstatement Application in CT - OL4374CT
Reinstatement Application in FL - OL4374FL
Reinstatement Application in GA - OL4374GA
Reinstatement Application in HI - OL4374HI
Reinstatement Application in IN - OL4374IN
Reinstatement Application in HI - OL4374HI
Reinstatement Application in MA - OL4374MA
Reinstatement Application in MD - OL4374MD
Reinstatement Application in ME - OL4374ME
Reinstatement Application in MI - OL4374MI
Reinstatement Application in MN - OL4374MN
Reinstatement Application in MO - OL4374MO
Reinstatement Application in NC - OL4374NC
Reinstatement Application in NE - OL4374NE
Reinstatement Application in NJ - OL4374NJ
Reinstatement Application in NM - OL4374NM
Reinstatement Application in NY - OL4374NY
Reinstatement Application in OH - OL4374OH
Reinstatement Application in OK - OL4374OK
Reinstatement Application in OR - OL4374OR
Reinstatement Application in PA - OL4374PA
Reinstatement Application in PR - OL4374PR
Reinstatement Application in SC - OL4374SC
Reinstatement Application in TX - OL4374TX
Reinstatement Application in UT - OL4374UT
Reinstatement Application in VA - OL4374VA
Reinstatement Application in VT - OL4374VT
Reinstatement Application in WA - OL4374WA
Most Commonly Requested Forms
Update the address we have on file with your policy. When filling out the form, be sure to include the name of annuitant or insured and the contract/policy number. Choose whether you are changing the address for the owner, annuitant, insured, assignee, or a recipient of a duplicate notice. Provide the name and contact information of the policy owner. This form requires the signature of the owner and joint owner (if any).
Use this form to make changes to your Federal or State tax withholding elections.
Change the beneficiary designation on any of of your life or annuity policies.
Automatically deposit checks for premium payment or premium deposit fund.
Update the name we have on file with your policy.
Designate individual(s) as new owner(s).
Request a loan on your policy.
Request an annuity partial surrender.
Variable Product Forms
Readjust investment allocations by shifting money among subaccounts.
Select an asset rebalancing or a dollar cost averaging investment program for your variable annuity.
Automated Subaccount Reallocation/Systematic Transfer Form - ASRST
Non-Individual Owner Forms
Relinquish the right, title and interest of the assignee to Nassau Life Insurance Company for a specific policy on the life of an insured individual
Power of attorney certification.
Certificate of Authority.
Inforce Underwriting Forms
Reinstate a policy
Reinstatement Application in AK - OL4374AK
Reinstatement Application in AZ- OL4374AZ
Reinstatement Application in CA - OL4374CA
Reinstatement Application in CT - OL4374CT
Reinstatement Application in FL - OL4374FL
Reinstatement Application in GA - OL4374GA
Reinstatement Application in HI - OL4374HI
Reinstatement Application in IN - OL4374IN
Reinstatement Application in MA - OL4374MA
Reinstatement Application in MD - OL4374MD
Reinstatement Application in ME - OL4374ME
Reinstatement Application in MI - OL4374MI
Reinstatement Application in MN - OL4374MN
Reinstatement Application in MO - OL4374MO
Reinstatement Application in NC - OL4374NC
Reinstatement Application in NE - OL4374NE
Reinstatement Application in NJ - OL4374NJ
Reinstatement Application in NM - OL4374NM
Reinstatement Application in NY - OL4374NY
Reinstatement Application in OH - OL4374OH
Reinstatement Application in OK - OL4374OK
Reinstatement Application in OR - OL4374OR
Reinstatement Application in PA - OL4374PA
Reinstatement Application in PR - OL4374PR
Reinstatement Application in SC - OL4374SC
Reinstatement Application in TX - OL4374TX
Reinstatement Application in UT - OL4374UT
Reinstatement Application in VA - OL4374VA
Reinstatement Application in VT - OL4374VT
Reinstatement Application in WA - OL4374WA
Apply for a change to an existing policy that requires underwriting for items like a change in lifestyle.
Convert part or all of an eligible term life insurance policy to a permanent policy
Term Conversion Application in AK - OL4776AK
Term Conversion Application in CA - OL4776CA
Term Conversion Application in FL - OL4776FL
Term Conversion Application in MA - OL4776MA
Term Conversion Application in ME - OL4776ME
Term Conversion Application for Use in CO, DE, KS, IL, MI, MO, NV, NM, OR, UT, VA, WY - OL4776ICC
Other Forms
Request electronic transfer for annuitized payments
Request a new contract if the original has been lost, misplaced or destroyed.
Request to annuitize a contract
Request a non-retirement payment from an outside company.
Most Commonly Requested Forms
Update the address we have on file with your policy. When filling out the form, be sure to include the name of annuitant or insured and the contract/policy number. Choose whether you are changing the address for the owner, annuitant, insured, assignee, or a recipient of a duplicate notice. Provide the name and contact information of the policy owner. This form requires the signature of the owner and joint owner (if any).
Update the name of the annuitant we have on file with your policy.
Use this form to make changes to your Federal or State tax withholding elections.
Authorize release of medical information to Nassau. This form may be used to authorize release of medical information to Nassau. If you live in Kansas, Massachusetts, Maine, Minnesota, New Mexico or Vermont, be sure to select the form specific to your state.
Change the beneficiary designation on any of of your life or annuity policies.
Automatically deposit checks for premium payment, premium deposit fund, or loan repayment.
Request that medical records used during the underwriting process be released to the individual whose information is to be released.
Update the name we have on file with your policy.
Designate individual(s) as new owner(s).
Designate which rider(s) you wish to surrender.
Variable Product Forms
Readjust investment allocations by shifting money among subaccounts.
Select an asset rebalancing or a dollar cost averaging investment program for your variable annuity.
Optional Investment Programs for Variable Annuities - OL4061
Use this form to select the subaccount(s) for your premium or loan payment allocation, or choose an asset allocation program for all annuities except Spectrum Edge+
- California residents cannot select subaccounts that are denoted not available in California.
- The Guaranteed Interest Account is not available for the Phoenix Income Choice product.
- You may select MVA as a subaccount option except for the following states: Maine, Maryland New Jersey, New York, Oregon, Pennsylvania, Texas and Washington.
- MVA is not available for the Phoenix Income Choice product.
Use this form to select the subaccount(s) for your premium or loan payment allocation.
Variable Universal Life Authorization for Payments, Transfers & Allocations - OL1320I
Agent and Broker Forms
Transfer responsibility for products to another agent or to another broker-dealer.
Inforce Underwriting Forms
Apply for non-smoker rates or non-smoker and neversmoke risk classification.
Apply for a change to an existing policy that requires underwriting for items like a change in lifestyle.
Applications for a Policy Change Fully Underwritten in AK - OL4755AK
Applications for a Policy Change Fully Underwritten in AZ - OL4755AZ
Applications for a Policy Change Fully Underwritten in CA - OL4755CA
Applications for a Policy Change Fully Underwritten in CT - OL4755CT
Applications for a Policy Change Fully Underwritten in FL - OL4755FL
Applications for a Policy Change Fully Underwritten in GA - OL4755GA
Applications for a Policy Change Fully Underwritten in HI - OL4755HI
Applications for a Policy Change Fully Underwritten in IN - OL4755IN
Applications for a Policy Change Fully Underwritten in MA - OL4755MA
Applications for a Policy Change Fully Underwritten in MD - OL4755MD
Applications for a Policy Change Fully Underwritten in ME - OL4755ME
Applications for a Policy Change Fully Underwritten in MN - OL4755MN
Applications for a Policy Change Fully Underwritten in MO - OL4755MO
Applications for a Policy Change Fully Underwritten in MT - OL4755MT
Applications for a Policy Change Fully Underwritten in NC - OL4755NC
Applications for a Policy Change Fully Underwritten in NE - OL4755NE
Applications for a Policy Change Fully Underwritten in NH - OL4755NH
Applications for a Policy Change Fully Underwritten in NM - OL4755NM
Applications for a Policy Change Fully Underwritten in NY - OL4755NY
Applications for a Policy Change Fully Underwritten in OH - OL4755OH
Applications for a Policy Change Fully Underwritten in OK - OL4755OK
Applications for a Policy Change Fully Underwritten in OR - OL4755OR
Applications for a Policy Change Fully Underwritten in PA - OL4755PA
Applications for a Policy Change Fully Underwritten in PR - OL4755PR
Applications for a Policy Change Fully Underwritten in SC - OL4755SC
Applications for a Policy Change Fully Underwritten in TX - OL4755TX
Applications for a Policy Change Fully Underwritten in UT - OL4755UT
Applications for a Policy Change Fully Underwritten in VA - OL4755VA
Applications for a Policy Change Fully Underwritten in VT - OL4755VT
Applications for a Policy Change Fully Underwritten in WA - OL4755WA
Applications for a Policy Change Fully Underwritten in WI - OL4755WI
Applications for a Policy Change Fully Underwritten in all other states - OL4755
Convert part or all of an eligible term life insurance policy to a permanent policy
Term Conversion Application in AK - OL4776AK
Term Conversion Application in CA - OL4776CA
Term Conversion Application in FL - OL4776FL
Term Conversion Application in MA - OL4776MA
Term Conversion Application in ME - OL4776ME
Term Conversion Application in NY - OL4776NY
Term Conversion Application for Use in CO, DE, KS, IL, MI, MO, NV, NM, OR, UT, VA, WY - OL4776ICC
Non-Individual Owner Forms
Designate a Non-Individual as new owner and beneficiary.
Designate a trust as new owner and beneficiary.
Certify the existence of a trust, as well as current trustees and/or successors.
Certification and Acknowledgement of Trust Agreement - OL4132A
Provide required details about the nature of the trust.
Certify that an individual is an elected and presently acting officer of entity, such as a corporation.
Authorize partners to sign on behalf of partnership that owns a policy for all matters related to the policy.
Relinquish the right, title and interest of the assignee to Nassau Life Insurance Company for a specific policy on the life of an insured individual
Assign your life insurance policy as collateral for a loan.
Request split-dollar administrative services: preparing collateral assignment or endorsement, or reporting the annual economic benefit.
Other Forms
File your required minimum distribution (RMD) election.
Give Nassau authority to share policy information with another party.
Disclosure Authorization for Release of Policy/Contract Information - HO5074A
Apply dividends to pay the balance of premiums becoming due by release of paid-up additions.
Request history of all policy account transactions for a specified period of time
Request a new contract if the original has been lost, misplaced or destroyed.
Request a change to information or instructions on a policy
Change a premium-paying policy to a paid-up status.
Restore a lapsed policy to active status.
Reinstatement Application in AK - OL4374AK
Reinstatement Application in AZ- OL4374AZ
Reinstatement Application in CA - OL4374CA
Reinstatement Application in CT - OL4374CT
Reinstatement Application in FL - OL4374FL
Reinstatement Application in GA - OL4374GA
Reinstatement Application in HI - OL4374HI
Reinstatement Application in IN - OL4374IN
Reinstatement Application in MA - OL4374MA
Reinstatement Application in MD - OL4374MD
Reinstatement Application in ME - OL4374ME
Reinstatement Application in MI - OL4374MI
Reinstatement Application in MN - OL4374MN
Reinstatement Application in MO - OL4374MO
Reinstatement Application in NC - OL4374NC
Reinstatement Application in NE - OL4374NE
Reinstatement Application in NJ - OL4374NJ
Reinstatement Application in NM - OL4374NM
Reinstatement Application in NY - OL4374NY
Reinstatement Application in OH - OL4374OH
Reinstatement Application in OK - OL4374OK
Reinstatement Application in OR - OL4374OR
Reinstatement Application in PA - OL4374PA
Reinstatement Application in PR - OL4374PR
Reinstatement Application in SC - OL4374SC
Reinstatement Application in TX - OL4374TX
Reinstatement Application in UT - OL4374UT
Reinstatement Application in VA - OL4374VA
Reinstatement Application in VT - OL4374VT
Reinstatement Application in WA - OL4374WA
For Health and Life (formerly Pyramid Life or Constitution Life*) Policyholders Only: Downloadable forms are not currently available online, please contact us
*For service or claims inquiries on your Pyramid Life or Constitution Life policy, please contact us at 1-800-999-2224. Please note: The Pyramid Life Insurance Company (“Pyramid Life”) and Constitution Life Insurance Company (“Constitution Life”) were renamed Nassau Life Insurance Company of Kansas (NLIC of Kansas) and Nassau Life Insurance Company of Texas (NLIC of Texas), respectively. NLIC of Texas merged into and became a part of Nassau Life and Annuity Company.
BPD: 40908