NEW YORK LIFE INSURANCE COMPANY
NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION (A Delaware Corporation)
NYLIFE INSURANCE COMPANY OF ARIZONA (Not licensed in every state)
STATEMENT OF TRUST - (For Trusts other than Testamentary Trusts)
Instructions:
•Use this form for Life and Annuity policies (new business and inforce changes).
•Do not use this form for a Testamentary Trust (a trust created within a will).
•Items 1-10 on page one must be completed in full.
•Complete page three and secure required signatures.
•For inforce policies, the Change of Beneficiary form (21131) and Transfer of Ownership form for life policies (21132) can be found in the Transfer of Ownership Life Kit (form 22600). The Transfer of Ownership form for annuity policies can be found in the Transfer of Ownership Annuity Kit (form 22599).
•Agent Certification section on page three must be completed and signed by agent - if your agent is assisting you with this change. If completing this form without an agent and the owner is a trust, please provide a copy of the trust agreement.
•In all instances New York Life reserves the right to request a copy of the trust if we deem it necessary.
Complete items 1-10 before proceeding
1.PROPOSED INSURED(s)/INSURED(s)/ANNUITANT(s)
2.POLICY NUMBER(s)
3. I/We affirm that the Trust Agreement created by
as Grantor/
SettLOr/Trustor is in effect and contains the following information:
4.Trust Name:
5.Trust Date:
6.State where Trust Established
7.Beneficiary(ies) of Trust:
8.Relationship of Trust Beneficiary(ies) to Proposed Insured(s)/Insured(s)/Annuitant(s):
9. Name(s) of Trustee(s):
Note: If more than one Trustee, we require all Trustees to sign applicable forms, unless we receive a copy of the Trust stating that the Trustees can act independently.
10.Relationship of Trustee(s) to
Proposed Insured(s)/Insured(s)/Annuitant(s):
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RETURN FORM TO: |
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For Variable Life and Variable Annuity policies: |
New York Life, Variable Products Service Center |
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Madison Square Station, PO Box 922, New York, NY 10159 |
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For all other policies:
If You Live In: AL, CT, DC, DE, FL, GA, IL, IN, KY, MA, ME, MD, MI, MS, NC, NH, NJ, NY, OH, PA, RI, SC, TN, VA, VT, WI, or WV, return this form to:
New York Life, Cleveland Service Center
PO Box 6916, Cleveland, OH 44101
If You Live In: AK, AR, AZ, CA, CO, HI, IA, ID, KS, LA, MN, MO, MT, NE, ND, NM, NV, OK, OR, SD, TX, UT, WA, or WY, return this form to:
New York Life, Dallas Service Center
PO Box 130539, Dallas, TX 75313-0539
Other: (i.e. foreign address, etc) return form to either location above.
