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Life Insurance Forms

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

  Download PDF (182 KB)

Change of Name or Address Form        Form # 15030
Aviva Life and Annuity Company
Used by policy owners to notify us in the event of a legal name change or to request a change to the current address on file.

  Download PDF (40 KB)

Change of Name or Address Form        Form # BL-089
Aviva Life and Annuity Company of New York
Used by policy owners to notify us in the event of a legal name change or to request a change to the current address on file.

  Download PDF (42 KB)

Change of Ownership Form        Form # 15028
Aviva Life and Annuity Company and Aviva Life and Annuity Company of New York
Use this form to transfer the ownership of your policy.

  Download PDF (257 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)

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 a non-approved provider.

  Download PDF (167 KB)

Pension Plan Verification        Form # 17982

Use this form to verify your pension plan.

  Download PDF (125 KB)

Policy Loan Request        Form # 15035
Aviva Life and Annuity Company
Used by policy owners to request a loan from their life insurance policy.

  Download PDF (38 KB)

Policy Loan Request Form        Form # BL-093
Aviva Life and Annuity Company of New York
Used by policy owners to request a loan from their life insurance policy.

  Download PDF (43 KB)

Bank Authorization Form        Form # 15036
Aviva Life and Annuity Company and Aviva Life and Annuity Company of New York
To have your premium payments automatically deducted from your checking account, submit this form and a void check or Specification Sheet from your account. Please contact the Home Office at least five days prior to your draft date for any changes to an existing Pre-Authorized Check agreement.

  Download PDF (202 KB)

Request for Co-Ownership        Form # 16283
Aviva Life and Annuity Company
This form is to be utilized any time there will be more than one owner.

  Download PDF (245 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)

Wellness for Life Program Qualification Form        Form # 16489
Aviva Life and Annuity Company
Used to stay qualified for the Wellness for Life program. Complete the Wellness for Life Program Qualification Form and have it signed by your doctor/health care provider at your regularly scheduled routine physical.

  Download PDF (100 KB)

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