Service Forms

We want to make it easy for you to help your clients

Most Commonly Requested Service Forms

File your required minimum distribution (RMD) election.

  Required Minimum Distribution (RMD) Election Form - OL4041

Use this form to make changes to your Federal or State tax withholding elections.

  Federal/State Income Tax Withholding Election - OL4753

Authorize the company to start paying benefits included in a Guaranteed Lifetime Withdrawal Rider

  Guaranteed Lifetime Withdrawal Rider Activation - OL4467

Give Nassau Re authority to share policy information with another party.

  Disclosure Authorization for Release of Policy/Contract Information - HO5074A

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).

  Address Change - OL4016

Update the account used for direct deposits sent to owner(s) of the policy/contract.

  Change Direct Deposit - OL4020

Certify the existence of a trust, as well as current trustees and/or successors.

  Certification and Acknowledgement of Trust Agreement - OL4132A

Update the name we have on file with your policy.

  Name Change - OL3135

Designate individual(s) as new owner(s).

  Ownership Change to Individual(s) - OL2346A

Designate a trust as new owner.

  Ownership Change to a Trust - OL2346E

Note: The Certification and Acknowledgment of Trust form must also be completed and submitted.

Change the beneficiary designation on any of of your life or annuity policies.

  Beneficiary Designation - OL122A

Additional Service Forms for client/policyholder use are available on .

Get information on how to file a claim.

Completed forms can be faxed to (321) 400-6316 or mailed to Nassau Re, PO Box 22012, Albany, NY 12201-2012