Form Number Description Type
Application Packets
Online Privacy Policy Online Privacy PolicyApplication Packets
PLB-3394Application Transmittal FormApplication Packets
Riders/Benefits Forms
PL-404R-NYChild Rider Medical DeclarationsRiders/Benefits Forms
CTR Packet NYChild Term Rider PacketRiders/Benefits Forms
PL-403R-NYRider WorksheetRiders/Benefits Forms
Questionnaires
PL-U663-NYAviation, Scuba Diving, Racing QuestionnaireQuestionnaires
PL-603-NYDrug and Alcohol Use QuestionnaireQuestionnaires
U-646-NYForeign Travel and Residence QuestionnaireQuestionnaires
PL-405R-NYConfidential Financial StatementQuestionnaires
PL-601-NYForeign National QuestionnaireQuestionnaires
PL-602-NYMilitary QuestionnaireQuestionnaires
PL-U657-NYMountain/Rock Climbing QuestionnaireQuestionnaires
F-LAD-315-NYTobacco QuestionnaireQuestionnaires
Conversion & Replacement Forms
B-7377 (NY)Life - Definition of Replacement - Appendix 11 (Life)Conversion & Replacement Forms
B-7376 (NY)Life - Disclosure Statement - Appendix 10A (Life)Conversion & Replacement Forms
B-7378 (NY)Life - Notice Regarding Replacement - Appendix 10C (Life)Conversion & Replacement Forms
B-8183-NYLife - Assignment/Transfer of Ownership Section 1035 ExchangeConversion & Replacement Forms
PL-502-NYApplication for Conversion or ExchangeConversion & Replacement Forms
Life - NY Reg-60 PackLife - New York Reg-60 PackConversion & Replacement Forms
B-8704NYLife - Notice to Insurer of Proposed Replacement (Life)Conversion & Replacement Forms
Authorization Forms
PL-HIPAA3-NYHIPAA Compliant AuthorizationAuthorization Forms
B-7032 (NY)Pre-authorized Bank Draft AgreementAuthorization Forms
APS-Special Authorization (New York Presbyterian)APS-Special Authorization (New York Presbyterian)Authorization Forms
PLX-425Cross Border Sales CertificationAuthorization Forms
Kaiser Permanente FormKaiser Permanente Form - All StatesAuthorization Forms
PLX-U398-NYParental Consent for Life Insurance PoliciesAuthorization Forms
Premium Payment
PL-CR-NY Conditional Receipt Agreement - NYPremium Payment
PL-104-NYPre-Authorized Withdrawal AgreementPremium Payment
Miscellaneous
PL-701-NYSupplement to Life Insurance Application (SOLI/IOLI) **REQUIRED FORM**Miscellaneous
PL-DIP-NY Description of Information PracticesMiscellaneous
F-LAD-410-NYTrust Certification (SOLI/IOLI)Miscellaneous
B (NY) InfoWho Can Receive HIV Related Information? (Consumer Notice) Miscellaneous
B-7375 (NY)Notice and Consent for Blood TestingMiscellaneous
PL-402-NYNon-Medical Declarations (Part 1A Medical)Miscellaneous
PLX-588Life Insurance Illustration Certification & AcknowledgementMiscellaneous
Military DA Form 2056Military DA Form 2056Miscellaneous
DD Form 2885Military - Personal Commercial Solicitation EvaluationMiscellaneous
F-588-R-NY (3/04)Assignment of Policy as Collateral SecurityMiscellaneous
PL-406-NY Continuation of Info for Pt I & II (Overflow Page)Miscellaneous
EOLINotice and Consent for Employer Owned Life InsuranceMiscellaneous
F-LAD-411-NYPremium Financing Disc & AcknowledgementMiscellaneous
PN-100R-NYSave Age FormMiscellaneous
PL-702-NYStatement of Owner Intent (SOLI/IOLI)Miscellaneous
Policy Service Forms
Tobacco Packet NYTobacco Use Questionnaire (for Rate Reclassification)Policy Service Forms
SVC-101-PLAAutomatic Premium LoanPolicy Service Forms
SVC-102-PLABeneficiary ChangePolicy Service Forms
SVC-103-PLABeneficiary with Mode of SettlementPolicy Service Forms
SVC-104-PLAChange of BrokerPolicy Service Forms
SVC-106-PLACo-Owner, Joint Owner, Ownership Common, ContingentPolicy Service Forms
SVC-130-PLACollateral AssignmentPolicy Service Forms
SVC-105-PLAContingent OwnershipPolicy Service Forms
SVC-107-PLACovered Insured BeneficiaryPolicy Service Forms
SVC-108-PLADividend and CouponPolicy Service Forms
SVC-109-PLADuplicate Policy - Policy Not LostPolicy Service Forms
F-ILD-228-NYGIO - Request to Exercise Option to Purchase Additional Life InsurancePolicy Service Forms
SVC-125-PLAIndexed Universal Life Fund Transfer/Allocation Change FormPolicy Service Forms
SVC-111-PLALoan FormPolicy Service Forms
SVC-114-PLAName ChangePolicy Service Forms
SVC-115-PLANon Forfeiture OptionsPolicy Service Forms
U-582 MECNotice Regarding Tax Treatment of Modified Endowment ContractsPolicy Service Forms
SVC-128-PLAPartial Assignment of Policy as Collateral SecurityPolicy Service Forms
SVC-116-PLAPartial SurrenderPolicy Service Forms
PLX-510Policy Change Application No EvidencePolicy Service Forms
PL-526-NY packetPolicy Change with Evidence PacketPolicy Service Forms
SVC-117-PLAPre Authorized WithdrawalPolicy Service Forms
PL-525-NY packetReinstatement PacketPolicy Service Forms
SVC-131-PLARelease of AssignmentPolicy Service Forms
SVC-118-PLASurrender Paid Up AdditionsPolicy Service Forms
SVC-119-PLATransfer of OwnershipPolicy Service Forms
W-8BENW-8BEN Tax FormPolicy Service Forms
W-8BEN InstructionsW-8BEN Tax Form InstructionsPolicy Service Forms
SVC-120-PLAWaiver of Community PropertyPolicy Service Forms
Examiner Forms (For Medical Examiner Use Only)
PL-103-NY_PL-406-NYMedical Exam FormExaminer Forms (For Medical Examiner Use Only)
PL-226R-NYSupplemental Underwriting Application **FOR MEDICAL EXAMINER USE ONLY**Examiner Forms (For Medical Examiner Use Only)
Agent Specific Forms
PLX-408-NYBroker/Representative ReportAgent Specific Forms