Forms

We’ve compiled frequently requested forms.

All forms are available in .pdf format. To view them, you will need Acrobat Reader, which is available free of charge from Adobe.

Frequently requested customer service forms for disability income insurance, life insurance, and retirement plans are available once you log in to your policy or contract.

Forms may be submitted to AuguStar^SM Financial by fax, email or mail.

By fax: 513.794.4730
By email: [email protected]
By U.S. Mail:
AuguStar Financial
P.O. Box 5308
Cincinnati, Ohio 45201-5308

Note: Documents may be faxed or emailed, but AuguStar^SM Financial reserves the right to request an original signature.

If you have any questions about these forms, please call Annuity Product Specialists at 888.925.6446.

Individual annuity forms

Title

Description

Form Number

Individual Annuity Contract Change Request – Full Surrender

The contract owner can complete this form to request a full withdrawal from an annuity. This will close the annuity. For contract details, rider effects or assistance filling out this form, please call the Annuity Product Specialist Team at 888-925-6446. Return form via mail, email or fax. Use for qualified or non-qualified contracts.

V-4619.3-A

Partial Withdrawal Form

The contract owner can complete this form to request a one-time partial withdrawal from an annuity. For contract limitations, rider effects or assistance filling out this form, please call the Annuity Product Specialist Team at 888-925-6446. This form may be returned via mail, email or fax. This form is used for qualified or non-qualified contracts.

V-4619.3-B

EFT / Bank Deposit Form

Complete this form to update banking instructions for a systematic withdrawal already on file. This form will NOT initiate a systematic withdrawal. For assistance filling out this form, call the Annuity Product Specialist Team at 888-925-6446. Return form via mail, email or fax. Use for qualified or non-qualified contracts.

V-4620-A

Systematic Withdrawal Form

Complete this form to set up a reoccurring withdrawal from an annuity. Can be based on the Rider, Free Withdrawal Amount, Interest Only, A Specific Dollar Amount or Percentage. For contract limitations, rider effects or assistance filling out this form, call the Annuity Product Specialist Team at 888-925-6446. Return form via mail, email or fax. Use for qualified or non-qualified contracts.

V-4620

Beneficiary Change Request

Complete to change beneficiaries named on an annuity contract and override the current beneficiary listing on file.

V-4614

Beneficiary Designation Information Sheet

This information sheet helps guide contract owners through the process of completing the Beneficiary Change Request form (V-4614) above. For assistance filling out the form, please call the Annuity Product Specialist Team at 888-925-6446. This form is used for qualified or non-qualified contracts.

V-4614-A

Individual Annuity Ownership Change Request

Complete form to change, add or delete an owner on annuity contract plus update date of birth or a name change for current owner. A Beneficiary Change or Agent Change form may be needed. Included is guide to complete the Ownership Change Form. For assistance, call the Annuity Product Specialist Team at 888-925-6446. Return form via mail, email or fax. Use for qualified or non-qualified contracts.

V-4611

Ownership Change Information Sheet

This information sheet is designed to help guide contract owners through the process of completing the Individual Annuity Ownership Change Request form (V-4611) above. For assistance filling out the form, please call the Annuity Product Specialist Team at 888-925-6446. Use for qualified or non-qualified contracts.

V-4611-A

Agent of Record/Broker Dealer Change Request

The contract owner can complete form to change the financial advisor associated with their annuity contract. Form cannot be used if the contract is custodially held. For more details or assistance filling out this form, please call the Annuity Product Specialist Team at 888-925-6446. Form may be returned via mail, email or fax. Use for qualified or non-qualified contracts.

V-4612

Third Party Investment Advisor Authorization Form (For ONcore Variable Annuities)

Complete form to add a third party financial advisor and allow the advisor to place trades on an annuity contract. A Third Party Advisor is unable to service or sell our annuity products, but is a licensed FINRA agent. For assistance, call the Annuity Product Specialist Team at 888-925-6446. Return form via mail, email or fax. Use for qualified or non-qualified contracts.

7216

Telephone Transfer Program Agreement Letter

Complete form to allow the financial advisor on file to place trades via a automated telephone system, augustarfinancial.com, or in writing. This form cannot be used for anyone except the financial advisor(s) listed on file. For assistance filling out this form, call the Annuity Product Specialist Team at 888-925-6446. Return form via mail, email or fax. Use for qualified or non-qualified contracts.

V-4832

ACH Debits (Bank Draft) Form

The contract owner completes this form to have reoccurring deposits come into their annuity contract from their bank account. Not available for Oregon ONcore, Top and Prime Series of Annuities. For assistance filling out this form, please call the Annuity Product Specialist Team at 888-925-6446. Return form via mail, email or fax. Use for qualified or non-qualified contracts.

V-4030-A

Individual Annuity Lost Policy Statement

Complete this form to request a duplicate copy of an annuity contract or use it together with a full surrender or transfer request to notify AuguStar Financial you have lost your original annuity contract. For assistance filling out this form, call the Annuity Product Specialist Team at 888-925-6446. Return form via mail, email or fax. Use for qualified or non-qualified contracts.

V-4615

Trustee Certification Form

Form is required when a Trust will be the Owner of an annuity contract. Trustee(s) should complete and sign form and write in title (Trustee or ttee) behind the signature. Submit a full copy of the Trust document. For assistance, call the Annuity Product Specialist Team at 888-925-6446. Return form via mail, email or fax. Use for qualified or non-qualified contracts.

V-4603

USA PATRIOT Act Compliance Form

Per federal regulations each Annuitant/Insured just complete, and if different than the Annuitant/Insured, also for each owner, payor and assignee. This form is required from all beneficiaries when a claim is filed. This form must be completed for individual owners when requesting an ownership change or when adding an owner. This form is used for qualified or non-qualified contracts.

6415

Individual Annuity Annuitization Request Forms

There are potentially multiple ways to Annuitize or enter the Lifetime Annuity Period, depending on contract specific circumstances. For more details specific to your contract or to have a form sent to you, please call the Annuity Product Specialist Team at 888-925-6446. All forms may be returned via mail, email or fax.

Multiple Forms

Automatic Minimum Distribution Election Statement

Complete to request the IRS required minimum withdrawal from a qualified plan if age 72 on a systematic basis. This form may be returned via fax. This form is used for qualified contracts only.

V-4622

GLWB Monthly RMD Election Form

This form is used for qualified contracts only.

V-4635

Products issued by AuguStar^SM Life Insurance Company and AuguStar^SM Life Assurance Corporation. Registered products distributed by AuguStar^SM Distributors, Inc., Member FINRA. Product, product features and rider availability vary by state. Guarantees are based upon the claims-paying ability of the issuer. Issuers not licensed to conduct business in New York. Withdrawals and loans may reduce the death benefit, cash surrender value and any living benefit amount.

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