Type | Description | Form Number |
| Application Packets
---|
Application Packets | Online Privacy Policy | Online Privacy Policy |
Application Packets | EZ Worksheet Packet - paper ticket with access to accelerated underwriting | EZ Worksheet |
Application Packets | Application Transmittal Form | PLB-3394 |
Application Packets | Informal Transmittal | F-LAD-325 |
Application Packets | TeleLife Fax Pre-Application for Term/UL | U-664-WA |
Application Packets | Term and Universal Life Application (Includes basic forms - single print) | ICC21-400R WA short |
Application Packets | Term and Universal Life Application (Includes supplemental forms - two sided print) | ICC21-400R WA packet |
Application Packets | Electronic Policy Delivery Form | ADMIN-2494214 |
Application Packets | Indexed Universal Life Application - Initial Allocation of Premiums | ICC13-IUL-SUPP |
Application Packets | **Variable Universal Life Application Packet | **ICC14-V1APP WA |
Application Packets | **Variable Universal Life Fund Allocations for SOVUL II - MUST ACCOMPANY VUL APP | **ICC21-V4FUND SOVULII |
Application Packets | **Variable Universal Life Fund Allocations for PIBA VUL - MUST ACCOMPANY VUL APP | **ICC21-V4FUND PIBA VUL |
Application Packets | Aspirations Variable Annuity Application Packet | Aspirations VA Pkt WA |
Application Packets | Protective Asset Builder II Annuity Application Packet 10 Year | Asset Builder II 10 BGA WA |
Application Packets | Protective Dimensions V Annuity Application | Dimensions V Multistate |
Application Packets | Protective Guaranteed Income Indexed Annuity Packet | PGIIA Packet WA |
Application Packets | Protective Income Builder with Guaranteed Income Benefit Application Packet | Income Builder WA |
Application Packets | Protective ProPayer Income Annuity Application Packet | IPD-2110-R1-WA AppPack |
Application Packets | Protective Secure Saver Application Packet | Secure Saver Packet WA |
Application Packets | Protective Variable Annuity Application Packet (B Series) | B Series VA for WA |
Application Packets | Protective Variable Annuity Application Packet (Investors Series) | Investors Series Pkt WA |
| Immediate Annuity Forms
---|
Immediate Annuity Forms | Authorization to Obtain and Disclose Information | LAD-1190 |
| Fixed Annuity Forms
---|
Fixed Annuity Forms | Appendix A Consumer Profile for use with Suitability Form | Appendix A |
Fixed Annuity Forms | Appendix B Consumer Profile for use with Suitability Form | Appendix B |
Fixed Annuity Forms | Appendix C Consumer Profile for use with Suitability Form | Appendix C |
Fixed Annuity Forms | Buyers Guide for Fixed & Equity Indexed Annuity Contracts**ALWAYS GIVE TO APPLICANT** | LAD-1189 |
Fixed Annuity Forms | Certificate of Trustee/Contract Owned by Trust | P-7019 |
Fixed Annuity Forms | Disability Certification Form | 3572-GEN-05 |
Fixed Annuity Forms | Fixed Annuitization Packet | LAD-1239 LAD-1126 |
Fixed Annuity Forms | Fund Transfer/Allocation Change Form | 3568-GEN-05 |
Fixed Annuity Forms | ProSaver Secure II Disclosure Statement | LAD-1228 Secure II Disclosure |
Fixed Annuity Forms | ProSaver Secure II Distribution Request Form | 3771-GEN-06 |
Fixed Annuity Forms | ProSaver Secure II Non-Financial Change Form | 3349-GEN-04 |
Fixed Annuity Forms | ProSaver Secure II Pre-Authorized Checking Agreement | 3352-GEN-04 |
Fixed Annuity Forms | ProSaver Secure II Systematic Distribution Form | 3361-GEN-04 |
Fixed Annuity Forms | ProSaver Secure R Disclosure Statement | LAD-1229 Secure R Disclosure |
Fixed Annuity Forms | Protective Guaranteed Income Indexed Annuity with Guaranteed Income Benefit Election Service Form | LAD-1233 PGIIAwGIB |
Fixed Annuity Forms | Protective Income Builder Rising Income Benefit Election | LAD-1233-RIB |
Fixed Annuity Forms | Protective Income Builder with Guaranteed Income Benefit Election Service Form | LAD-1233 PIBwGIB |
Fixed Annuity Forms | Protective Income Manager Withdrawal Form | LAD-1216 |
Fixed Annuity Forms | Required Distribution Election Form for IRA and 403(b) Contracts | 3566-GEN-05 |
Fixed Annuity Forms | SecurePay Benefit Election | LAD-1233-SEC |
Fixed Annuity Forms | Telephone Transfer Authorization for Annuities | LAD-1242 |
Fixed Annuity Forms | Terminal Illness Certification Form | 3573-GEN-05 |
Fixed Annuity Forms | Unemployment Certification Form | 3574-GEN-04 |
| TeleLife
---|
TeleLife | TeleLife Application Packet | TeleLife WA |
TeleLife | TeleLife Application Packet - VUL | TeleLife VUL WA |
| Riders/Benefits Forms
---|
Riders/Benefits Forms | Rider Worksheet | ICC20-403R |
Riders/Benefits Forms | Child Rider Medical Declarations | ICC17-404R |
Riders/Benefits Forms | Child Term Rider Packet | CTR Packet Compact |
Riders/Benefits Forms | Disclosure Form for Chronic Illness Accelerated Death Benefit Rider | L652-DSC |
Riders/Benefits Forms | Hold Harmless Agreement for Employer Owned Policy with ECR | HHA-ECR-Employer |
Riders/Benefits Forms | Hold Harmless Agreement for Trust Owned policy with ECR | HHA-ECR-Trust |
Riders/Benefits Forms | Hold Harmless Agreement-One Insured-Multiple Policies with ECR | HHA-OneIns-MultECR |
Riders/Benefits Forms | Income Provider Option - Pre-Determined Death Benefit Payout Endorsement | ICC18-437R |
| Questionnaires
---|
Questionnaires | Aviation, Scuba & Racing Questionnaire | ICC19-U663 |
Questionnaires | Confidential Financial Statement | ICC20-405R |
Questionnaires | Diabetic Questionnaire | U-102P-11/83 |
Questionnaires | Drug and Alcohol Use Questionnaire | ICC20-603 |
Questionnaires | Foreign National Questionnaire | ICC15-601 |
Questionnaires | Foreign Travel and Residence Supplement | ICC13-PU646 |
Questionnaires | Military Questionnaire | ICC18-PL602 |
Questionnaires | Mountain/Rock Climbing Questionnaire | ICC19-U657 |
Questionnaires | Parachute/Sky Diving Questionnaire | ICC13-PU601 |
Questionnaires | Tobacco Use Questionnaire (for New Business) | ICC12-600 10/12 |
| Conversion & Replacement Forms
---|
Conversion & Replacement Forms | Assignment/Transfer of Ownership Section 1035 Exchange | F-LAD-277 |
Conversion & Replacement Forms | (Annuity) Replacement Form (External/Internal) | A1128WA (Ann) |
Conversion & Replacement Forms | (Life) Replacement Form (External/Internal) | A1128WA (Life) |
Conversion & Replacement Forms | 1035 Exchange Form | U-379-R6 |
Conversion & Replacement Forms | Application for Conversion or Exchange | ICC13-502 Pkt Generic |
Conversion & Replacement Forms | Application for Conversion or Exchange to SOVUL II | ICC17-V234 SOVULII |
Conversion & Replacement Forms | Assignment/Transfer of Ownership with Transfer of Outstanding Loan | U-640 |
Conversion & Replacement Forms | Dimensions V RightTime Election Form | LAD-1198 DIM V |
Conversion & Replacement Forms | SecurePay Income Benefit Election for Dimensions V | LAD-1233-DIM V |
| Authorization Forms
---|
Authorization Forms | Authorization to Obtain and Disclose Information (HIPAA) | ICC21-HIPAA3 |
Authorization Forms | Cross Border Sales Certification | PLX-425 |
Authorization Forms | Kaiser Permanente Form - All States | Kaiser Permanente |
Authorization Forms | Parental Consent for Life Insurance Policies | PLX-U398 |
| Premium Payment
---|
Premium Payment | Pre-Authorized Withdrawal Form | PL-104 |
Premium Payment | Conditional Life Receipt | PL-CR |
Premium Payment | Employee Payroll Deduction Authorization Form | F-LAD-416 (12/08) |
Premium Payment | Pre-Authorized Withdrawal Form | F-706-R8 |
| Transfer of Assets and Administrative Annuity Forms
---|
Transfer of Assets and Administrative Annuity Forms | Annuity Suitability Form | LAD-1243R Annuity Suitability |
Transfer of Assets and Administrative Annuity Forms | Assignment of Policy as Collateral Security for Annuities | LAD-1235 |
Transfer of Assets and Administrative Annuity Forms | Automatic Deposit Agreement Form | LAD-1162 |
Transfer of Assets and Administrative Annuity Forms | Automatic Purchase Plan | LAD-1128 |
Transfer of Assets and Administrative Annuity Forms | B Series - Payments, Allocations and Transfers | LAD-1121 VA II B Series |
Transfer of Assets and Administrative Annuity Forms | B Series II PIM RightTime Election Form | LAD-1217-B |
Transfer of Assets and Administrative Annuity Forms | B Series II SecurePay RightTime Election Form | LAD-1198-B |
Transfer of Assets and Administrative Annuity Forms | Contract Change Request | LAD-1127 |
Transfer of Assets and Administrative Annuity Forms | Dimensions IV - Payments, Allocations and Transfers | LAD-1121 DIM IV |
Transfer of Assets and Administrative Annuity Forms | Dimensions V - Payments, Allocations and Transfers | LAD-1121 DIM V |
Transfer of Assets and Administrative Annuity Forms | FIA Indexed Annuity Allocations | LAD-1232 |
Transfer of Assets and Administrative Annuity Forms | Internal Exchange Procedures | LAD-1132 7/09 |
Transfer of Assets and Administrative Annuity Forms | Investors Series - Allocation Adjustment Program | LAD-1236-PVA-IS |
Transfer of Assets and Administrative Annuity Forms | Investors Series - Payments, Allocations and Transfers | LAD-1121-PVA-IS |
Transfer of Assets and Administrative Annuity Forms | Lost Policy Statement | LAD-1175 |
Transfer of Assets and Administrative Annuity Forms | Payments, Allocations and Transfers for Aspirations Variable Annuity | LAD-1121 Aspirations |
Transfer of Assets and Administrative Annuity Forms | Pre-Determined Death Benefit Payout Election | LAD-1153 |
Transfer of Assets and Administrative Annuity Forms | Request for Transfer or Exchange of Assets **REQUIRED FOR TRANSFERS** | LAD-1120 |
Transfer of Assets and Administrative Annuity Forms | SecurePay Benefit Election for Aspirations Variable Annuity | LAD-1233 Aspirations |
Transfer of Assets and Administrative Annuity Forms | SecurePay RightTime Election Form for Aspirations Variable Annuity | LAD-1198 Aspirations |
Transfer of Assets and Administrative Annuity Forms | Stretch Annuity Information | LAD-1166 |
| Miscellaneous
---|
Miscellaneous | Premium Financing Disc & Acknowledgement | F-LAD-411 |
Miscellaneous | Statement of Owner Intent (SOLI/IOLI) | ICC14-PL702 |
Miscellaneous | Trust Certification (SOLI/IOLI) | ICC13-LAD410 |
Miscellaneous | Non-Medical Declarations (Part 1A Medical) | ICC12-402 |
Miscellaneous | Continuation of Information | ICC13-406A |
Miscellaneous | Supplement to Life Insurance Application (SOLI/IOLI) ** REQUIRED FORM** | ICC14-PL701 |
Miscellaneous | Advertising Request Form | MK-269 (5/00) |
Miscellaneous | Description of Information Practices | PL-DIP |
Miscellaneous | Explanation of Coverage - for Broker/Dealer use only. | Explanation of Coverage |
Miscellaneous | HIV Consent Form | U-412 |
Miscellaneous | Intent to Buy - fillable | Intent to Buy |
Miscellaneous | IVES Request for Transcript of Tax Return | IRS Form 4506c |
Miscellaneous | Life Insurance Illustration Certification & Acknowledgement | PLX-588 |
Miscellaneous | Military - Personal Commercial Solicitation Evaluation | DD Form 2885 |
Miscellaneous | Military DA Form 2056 | Military DA Form 2056 |
Miscellaneous | Military Sales Disclosure Form | PLX-602 |
Miscellaneous | Notice and Consent for Employer Owned Life Insurance | EOLI |
Miscellaneous | Order Form for Business Cards, Letterhead & Envelopes | MK-283 (7/00) |
Miscellaneous | Save Age Form | ICC21-PN-100R |
Miscellaneous | SEP IRA Forms for B Series VA, Investors Series VA, Dimensions IV VA, and Aspirations VA | SEP IRA Agreement |
Miscellaneous | UL Exchange | F-1241 |
Miscellaneous | W9 Tax Form | W-9 |
| Policy Service Forms
---|
Policy Service Forms | Automatic Premium Loan | SVC-101-PL |
Policy Service Forms | Beneficiary Change | SVC-102-PL |
Policy Service Forms | Beneficiary Change of Last Will & Testament | F-787 (9/99) |
Policy Service Forms | Beneficiary Information Request | LAD-1225 |
Policy Service Forms | Beneficiary with Mode of Settlement | SVC-103-PL |
Policy Service Forms | Buyer's Guide for Annuities | BG-13 Buyer's Guide for Annuities |
Policy Service Forms | Change of Broker | SVC-104-PL |
Policy Service Forms | Co-Owner, Joint Owner, Ownership Common, Contingent | SVC-106-PL |
Policy Service Forms | Collateral Assignment Form | SVC-130-PL |
Policy Service Forms | Contingent Ownership | SVC-105-PL |
Policy Service Forms | Covered Insured Beneficiary | SVC-107-PL |
Policy Service Forms | Dividend and Coupon | SVC-108-PL |
Policy Service Forms | Duplicate Policy - Policy Not Lost | SVC-109-PL |
Policy Service Forms | Full Surrender Form | SVC-110-PL |
Policy Service Forms | Indexed Universal Life Fund Transfer/Allocation Change Form | SVC-125-PL |
Policy Service Forms | Loan Form | SVC-111-PL |
Policy Service Forms | Monthly Level Transfer (MLT) for Indexed Universal Life Insurance | SVC-135-PL |
Policy Service Forms | Name Change | SVC-114-PL |
Policy Service Forms | Non Forfeiture Options | SVC-115-PL |
Policy Service Forms | Notice Regarding Tax Treatment of Modified Endowment Contracts | U-582 MEC |
Policy Service Forms | Partial Assignment of Policy as Collateral Security | SVC-128-PL |
Policy Service Forms | Partial Surrender WA | SVC-116-PL Washington |
Policy Service Forms | Policy Change Application No Evidence | PLX-510 |
Policy Service Forms | Policy Change with Evidence Packet | ICC13-P526 for WA packet |
Policy Service Forms | Pre-Authorized Withdrawal | SVC-117-PL |
Policy Service Forms | Reinstatement Packet | ICC13-P525 for WA packet |
Policy Service Forms | Release of Assignment | SVC-131-PL |
Policy Service Forms | Request to Exercise Option to Purchase Additional Life Insurance | F-ILD-228 |
Policy Service Forms | Service Request Form | F-LAD-233 with PAW |
Policy Service Forms | Statement of Health | U-253 |
Policy Service Forms | Surrender Paid Up Additions | SVC-118-PL |
Policy Service Forms | Tax Withholding on Periodic Annuity Payments | LAD-1114 |
Policy Service Forms | Telephone Withdrawal Authorization | LAD-1155 |
Policy Service Forms | Tobacco Use Questionnaire Packet (for Rate Reclassification) | Tobacco Packet WA |
Policy Service Forms | Transfer of Ownership | SVC-119-PL |
Policy Service Forms | VUL - Transfer Authorization | LAD-1247 |
Policy Service Forms | W-8BEN Tax Form | W-8BEN |
Policy Service Forms | W-8BEN Tax Form Instructions | W-8BEN Instructions |
Policy Service Forms | Waiver of Community Property | SVC-120-PL |
Policy Service Forms | Withdrawal Request Form | LAD-1147 |
| Examiner Forms (For Medical Examiner Use Only)
---|
Examiner Forms (For Medical Examiner Use Only) | Part II Statements Made to Examiner | PL-103_ICC13-406A |
Examiner Forms (For Medical Examiner Use Only) | Authorization to Obtain and Disclose Information (HIPAA) | ICC21-HIPAA3 medical examiner |
Examiner Forms (For Medical Examiner Use Only) | Landmark Copy Drawing Test **FOR EXAMINER USE ONLY** | F-LAD-402 |
Examiner Forms (For Medical Examiner Use Only) | Supplemental Underwriting Application ** FOR MEDICAL EXAMINER USE ONLY | ICC13-P226 |
| Agent Specific Forms
---|
Agent Specific Forms | Broker/Representative Report | PLX-408 |
Agent Specific Forms | APS Reimbursement Request Form | PL-APS |
Agent Specific Forms | Broker/Representative Report EDJ | PLX-408 EDJ |
Agent Specific Forms | VUL - Broker/Representative Report | PLX-V408 |
Agent Specific Forms | VUL - Broker/Representative Report EDJ | PLX-V408 EDJ |