The insurer identified above will be referred to herein as the "Company"
Individual Annuity Application
Please print or type:
Primary Owner Individual
(For Trust Ownership, provide the completed Trust Certification form.)
Non-Person Entity
Male
Female
Sex Legal Name (First, Middle, Last, Suffix) Social Security Number/TIN
Date of Birth/Trust Date
Marital Status
Driver’s License Number, State and Expiration (If none, provide alternate ID type, issuer, number and expiration date.) Residence Address or Legal Address State
City
Zip Code
Mailing Address (If different from Residence Address.) City
State
Zip Code
Primary Phone
Email Address
No Yes Is the Proposed Owner a member of GBU Financial Life?
Joint Owner
(Must be spouse of the Primary Owner. Available for non-qualified annuities only.) Male
Legal Name (First, Middle, Last, Suffix) Social Security Number
Female
Sex Date of Birth
Marital Status
Driver’s License Number, State, and Expiration (If none, provide alternate ID type, issuer, number and expiration date.) Residence Address or Legal Address City
State
Zip Code
Primary Phone
Email Address
GBU FINANCIAL LIFE
www.gbu.org newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 800-765-4428 ICC21-ANA
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