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 Forms
Annuity Forms

We’ve compiled our most frequently requested customer service forms.

All the forms are in pdf and are available for viewing over the Internet with the Adobe Acrobat Reader. Acrobat Reader is available free of charge from Adobe.

Fax forms to: 513.794.4730 (Please note, not all forms can be returned via fax. Some forms require original signatures. Please call customer service to confirm.)

Mail to:
National Security Life and Annuity Company
Administrative Office
P.O. Box 5363
Cincinnati, OH 45201-5363

If you have any questions about completing any of these forms, please call Annuity Client Services at 877.446.6020 or e-mail NSCustomerService@nslac.com.
PDF Title Description Form# 
1 Agent of Record/Broker Dealer Change Request Complete this form to change the financial advisor associated with an existing annuity contract. Not applicable to custodially owned contracts. V-4612-NSLAC
2 ACH Debits (Bank Draft) Form Use to authorize direct payments from the account of your choice to make a purchase or premium payment on your policy/contract. This form may be returned via fax. NS-4030-NY
3 Beneficiary Change Request Complete this form to change beneficiaries on an existing annuity contract. V-4614-NSLAC
4 EFT Agreement Complete form to have payments directly deposited into an account of your choice. V-4620-A-NSLAC
5 GLWB Monthly RMD Election This form should be used to elect the GLWB rider's Monthly Required Minimum Distribution Treatment (monthly RMD) provision. For qualified contracts only. V-4635-NSLAC
6 Individual Annuity Contract Annuitization Request Packet Use to annuitize a contract. This form may be returned via fax. V-4607-E-NSLAC
7 Annuity Lost Contract Statement Complete form together with a full surrender or transfer request to notify National Security you have lost your original annuity contract and will not be returning it at the time of the full surrender. V-4615-NSLAC
8 Annuity Ownership Change Request Use this form to (1) change, add or delete an owner on an existing annuity contract (2) update the owner’s date of birth and/or (3) submit a name change for the current owner. Included is a guide to complete the Annuity Ownership Change Form. V-4611-NSLAC
9 Systematic Withdrawal Form Complete form to start a series of partial surrenders V-4620-NSLAC
10 TeleAccess Authorization and Limited Power of Attorney Telephone and Internet Trade Authorization Agreement NS-V-4832
11 USA Patriot Act Compliance Form Per federal regulations, complete for each Annuitant; and if different than the Annuitant, for each owner, payor and assignee. This form is also required on all beneficiaries when a claim is filed. This form needs to be completed for an individual owners when requesting an ownership change or when adding an owner. An original copy is required. Please return via mail. 6415-NSLAC
 
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