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Annuity Forms

Additional Beneficiaries Designation-Supplement to Beneficiary Change Request        Form # 17963
Aviva Life and Annuity Company and Aviva Life and Annuity Company of New York
Use this form to elect Additional Beneficiaries for your contract(s), if you do not have enough space on Form 13977 (Beneficiary Change Request).

  Download PDF (244 KB)

Annuity Buyer's Guide        Form # 15500
Aviva Life and Annuity Company and Aviva Life and Annuity Company of New York
Buyer's Guide to Fixed Deferred Annuities with Appendix for Equity-Indexed Annuities

  Download PDF (3.12 MB)

Annuity Buyer's Guide - KY        Form # 80333
Aviva Life and Annuity Company
Kentucky Buyer's Guide to Annuities

  Download PDF (148 KB)

Annuity Buyer's Guide - WI        Form # 14221
Aviva Life and Annuity Company
Wisconsin Buyer's Guide to Annuities

  Download PDF (24 KB)

Authorization to Release Information        Form # 55422
Aviva Life and Annuity Company
Use this form to authorize someone to receive information about your policy/contract.

  Download PDF (140.3 KB)

Beneficiary Change Request        Form # 13977
Aviva Life and Annuity Company
Use the change beneficiary form to change a primary or contingent beneficiary.

  Download PDF (181 KB)

Change of Ownership Form        Form # 17860
Aviva Life and Annuity Company
Use this form to transfer the ownership of your policy.

  Download PDF (241 KB)

Confinement Withdrawal Packet        Form # 17861KT
Aviva Life and Annuity Company
Use this form to request a withdrawal under the Confinement Waiver of your contract.

  Download PDF (190 KB)

Electronic Funds Transfer Form        Form # 10054
Aviva Life and Annuity Company
Bank authorization for direct deposit.

  Download PDF (172 KB)

Income Rider Withdrawal Request for BPA Income Advantage and BAA Income Advantage        Form # 17411
Aviva Life and Annuity Company
Use this form to begin receiving payments under the Income Rider of your contract.

  Download PDF (180KB)

Income Rider Withdrawal Request for Fixed Products        Form # 17284
Aviva Life and Annuity Company
Use this form to begin receiving payments under the Income Rider of your contract.

  Download PDF (180KB)

Income Rider Withdrawal Request for Indexed Products        Form # 17285
Aviva Life and Annuity Company
Use this form to begin receiving payments under the Income Rider of your contract.

  Download PDF (172KB)

Income Rider Withdrawal Request for LifeTime Solutions Annuity        Form # 17973
Aviva Life and Annuity Company and Aviva Life and Annuity Company of New York
Use this form to begin receiving payments under the Income Rider of your contract.

  Download PDF (146KB)

Information Sharing Agreement        Form # 81061
Aviva Life and Annuity Company
Use this form to agree to an information sharing agreement.

  Download PDF (174 KB)

Information Sharing Agreement Non-Approved Provider        Form # 81060
Aviva Life and Annuity Company
Use this form to agree to an information sharing agreement with an non-approved provider.

  Download PDF (167 KB)

Pension Plan Verification        Form # 17982
Aviva Life and Annuity Company and Aviva Life and Annuity Company of New York
Use this form to verify your pension plan.

  Download PDF (125 KB)

Request for Service Form        Form # 57201
Aviva Life and Annuity Company (formerly American Investors Life Insurance Company, Inc.)
Transfer of ownership, name contingent owner, change of name, address change, or beneficiary change.

  Download PDF (197 KB)

Systematic Withdrawal Form        Form # 57200
Aviva Life and Annuity Company (formerly American Investors Life Insurance Company, Inc.)
Use when customer requests systematic withdrawals.

  Download PDF (109 KB)

Terminal Illness Withdrawal Packet        Form # 17864KT
Aviva Life and Annuity Company
Use this form to request a withdrawal under the Terminal Illness Waiver of your contract.

  Download PDF (165 KB)

Trust Verification Form        Form # 16541
Aviva Life and Annuity Company and former American Investors Life Insurance Company, Inc.
Used by policy owners, in lieu of the complete copy of the trust, to certify the name, date and trustees of their trust.

  Download PDF (25 KB)

W-9 Taxpayer ID Form        Form # 9393
Aviva Life and Annuity Company, Aviva Life and Annuity Company of New York, and former American Investors Life Insurance Company, Inc.
Used by policy owners to certify their TID# of SS# is correct for the purpose of proper tax reporting.

  Download PDF (37KB)

Withdrawal Request        Form # 13980
Aviva Life and Annuity Company
Use this form to request a withdrawal from your contract.

  Download PDF (146 KB)

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