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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

PDF Title Description Form# 
1 Agent of Record/Broker Dealer Change Request Owner should complete to change the servicing representative on the contract. This form cannot be used for custodially-owned contracts. This form may be returned via fax. 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 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. V-4622-NSLAC
4 Beneficiary Change Request Complete form to update beneficiary designation on a contract. V-4614-NSLAC
5 EFT / Bank Deposit Form Complete form to have payments directly deposited into an account of your choice. V-4620-A-NSLAC
6 GLWB Monthly RMD Election Form   V-4635-NSLAC
7 Individual Annuity Contract Annuitization Request Packet Use to annuitize a contract. This form may be returned via fax. V-4607-E-NSLAC
8 Individual Annuity Contract Change Request - Full Surrender Complete form to request a full surrender V-4619.3-A-NSLAC
9 Individual Annuity Contract Change Request - Partial Surrender Complete form to request a partial surrender V-4619.3-B-NSLAC
10 Individual Annuity Lost Policy 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. Please return via mail. V-4615-NSLAC
11 Individual Annuity Ownership Change Request Complete form to change ownership of the annuity, to change the name of an annuitant or owner, or update the date of birth of the annuitant or owner. Please call customer service to see if this form may be returned via fax. V-4611-NSLAC
12 Systematic Withdrawal Form Complete form to start a series of partial surrenders V-4620-NSLAC
13 TeleAccess Authorization and Limited Power of Attorney Telephone and Internet Trade Authorization Agreement NS-V-4832
14 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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