Transcription of Contract Change Request and Medical Questionnaire
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Contract Change Request and Medical Questionnaire
APO-1270-R11/2013 Contract Change Request and Medical Questionnaire Mail to: Nationwide Life Insurance Company and Nationwide Life and Annuity Insurance Company Individual Annuities, Box 182021, Columbus, Ohio, 43218-2021, 1-800-848-6331, Fax to: 1-888-634-4472 Page 1 of 5 Supplemental information MUST be completed for all of the following owner Information (Please print.) All fields in this section are Change of Annuitant (Annuitant changes are not permitted on existing contracts with the Option.) Must include completed New Business Application and completed Medical Proposed Primary AnnuitantAnnuitant First/Last Name: Relationship to current Contract owner : Date of Birth: State of Birth: Soc. Sec. No. Address: City/State/ZIP: Telephone Number: ( ) E-mail Address: The Annuity Commencement Date* will automatically be updated to the later of the new annuitant s 95th birthday or two (2) years from the date this form is received in good order, unless another future date is indicated below:Annuity Commencement Date: / / (Optional) MM DD YYYY*Annuity Commencement Date (ACD) is the date on which annuity payments are scheduled to begin.
APO-1270-R 11/2013 Contract Change Request and Medical Questionnaire Page 2 of 5 3. New Contract Owner • Ownership changes may result in a taxable event.
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