Agent/Producer Internal Transfer Verification Form by GBULife

Agent/Producer Internal Transfer Verification Form

Policy Number

Contract Owner’s Name

Account Type—Select only ONE (MUST Provide ADDITIONAL Form For Each Account Being Transferred).

Full Transfer

Partial – Specific Amount $

Qualified (Traditional IRA, Roth IRA, SEP)

Non-Qualified

Penalty Free (Maximum Available)

Required Minimum Distribution Instructions (If Applicable)

RMD - Continue Instructions on File with GBU

RMD - NEW Insructions (MUST Also Provide Required Minimum Distribution Service Request Form)

RMD - To Be Provided at a Later Date

Full Transfer

Partial – Specific Amount $

Penalty Free (Maximum Available)

Systematic Payments

Continue Instructions of File with GBU

NEW Instructions (Select ONLY one): Interest ONLY Payments OR Specific $

Payment Frequency: Monthly Quarterly Semi-Annually Annually

Taxation: Withold $ or % for federal income tax.

* GBU will withhold 10% from the taxable portion of your withdrawal, unless you elect otherwise. GBU does not withhold any state tax. Please consult your tax advisor with any questions on taxation.

Payment Method: Cash to Owner Transfer to GBU Account

Special Instructions

No Instructions at This Time

Direct Deposit Bank Draft Authorization

Continue Instructions on File with GBU

NEW Instructions NEW Instructions (MUST Also Provide Electronic Direct Deposit Authorization Form) (MUST Also Provide Bank Draft Authorization Form)

Phone: 412-884-5100 | 800-765-4428 | service@gbu.org | gbu.org

GBU-AGENT-TVF-0123 Page 1 of 1 Rev. 01/2023

No Instructions At This Time No Instructions At This Time Agent/Producer Signature GBU USE ONLY Print Date From: To: Q/NQ: Full/Par tial: Amount: PF Sign Policy

Processor Page of

Date:

4254 Saw Mill Run Blvd., Pittsburgh, PA 15227