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Annuity Forms

Electronic Funds Transfer Form Form # 50276
Aviva Life and Annuity Company (formerly American Investors Life Insurance Company, Inc.)
Bank authorization for direct deposit.

Download PDF (68 KB)

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

Download PDF (200 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)

Request for Service Form Form # 13978
Aviva Life and Annuity Company
Use when customer requests systematic withdrawals, to name contingent owner, change of name, address change, or beneficiary change.

Download PDF (26 KB)

Required Minimum Distribution Request Form Form # 53000
Aviva Life and Annuity Company (formerly American Investors Life Insurance Company, Inc.)
Use when minimum withdrawals are required for distribution.

Download PDF (293 KB)

Required Minimum Distribution Request Form Form # 10042
Aviva Life and Annuity Company
Use when minimum withdrawals are required for distribution.

Download PDF (466 KB)

Systematic Withdrawal Form Form # 83000
Aviva Life and Annuity Company
Use when customer requests systematic withdrawals.

Download PDF (127 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)

Transfer of Ownership Form Form # 13977
Aviva Life and Annuity Company
Use when customer requests a transfer of ownership.

Download PDF (19 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 or Surrender Form Form # 53069
Aviva Life and Annuity Company (formerly American Investors Life Insurance Company, Inc.)
Use to withdraw or surrender a single premium or flexible premium annuity.

Download PDF (23 KB)

Life Insurance Forms

Change of Beneficiary Form Form # 15029
Aviva Life and Annuity Company
Use the change of beneficiary form to change a primary or contingent beneficiary designation.

Download PDF (44 KB)

Change of Beneficiary Form Form # BL-088
Aviva Life and Annuity Company of New York
Use the change of beneficiary form to change a primary or contingent beneficiary designation.

Download PDF (45 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
Use this form to transfer the ownership of your policy.

Download PDF (42 KB)

Change of Ownership Form Form # BL-087
Aviva Life and Annuity Company of New York
Use this form to transfer the ownership of your policy.

Download PDF (49 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
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 (41 KB)

Pre-Authorized Check Authorization Form Form # BL-094
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 (45 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 (24 KB)

Download PDF (25 KB)

Trust Verification Form # 1067NY
Aviva Life and Annuity Company of New York
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 (26 KB)

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)

Contact Aviva

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Or call toll-free at 1 800 800 9882

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Your independent local Aviva agent can help you with any questions you may have.

Or call toll-free at 1 800 800 9882