Service Forms

File Name
Updated
Monument Advisor Investment Instructions (PDF) 09/08/2023
Monument Advisor Select Investment Instructions (PDF) 09/08/2023
Service Form (PDF) 09/08/2023
Advisor Authorization Agreement (PDF) 08/25/2023
Advisor Fee Instructions (PDF) 08/25/2023
Agent Enrollment Request Form - VA 128 (PDF) 08/25/2023
Annuity Beneficiary Claim Form (PDF) 08/25/2023
Annuity Contract Change Request Form - VA 109 (PDF) 08/25/2023
Beneficial Owner Life Expectancy Distribution Administration Form (PDF) 08/25/2023
Beneficiary Change Request (PDF) 08/25/2023
Chronically Ill or Disabled Individual Physician Certification Form (PDF) 08/25/2023
Collateral Assignment Form VA 106 (PDF) 08/25/2023
Contract Owner Withdrawal For Non-Qualified Contracts (PDF) 08/25/2023
Contract Owner Withdrawal For Qualified Contracts (PDF) 08/25/2023
Contribution Form - VA 113 (PDF) 08/25/2023
Deferred Annuitization Election Form (PDF) 08/25/2023
Due Diligence Supplement - VA 123 (PDF) 08/25/2023
Financial Adviser and Broker Dealer Change Request Form - FA CHG (PDF) 08/25/2023
Payout Beneficiary Claim Form (PDF) 08/25/2023
Qualified Birth or Adoption Distribution Repayment Form (PDF) 08/25/2023
Required Minimum Distribution (RMD) Request Form (PDF) 08/25/2023
Restriction of Beneficiary Options (PDF) 08/25/2023
Substantially Equal Periodic Payments (SEPP) Form (PDF) 08/25/2023
TSA Hardship Withdrawal Request Form (PDF) 08/25/2023
TSA Loan Request Form - VA 105 (PDF) 08/25/2023
Transfer and Allocation Form - VA 118 (PDF) 08/25/2023
Transfer of Assets and Replacement for AK,AL,AZ,CO,CT,HI,IA,KY,LA,MD,ME,MO,MS,NC,NE,NH,NJ,NM,OH,OR,SD,TX,UT,VT,WI,WV (PDF) 08/25/2023
Transfer of Assets and Replacement for AR (PDF) 08/25/2023
Transfer of Assets and Replacement for CA (PDF) 08/25/2023
Transfer of Assets and Replacement for DC, ND (PDF) 08/25/2023
Transfer of Assets and Replacement for DE (PDF) 08/25/2023
Transfer of Assets and Replacement for FL (PDF) 08/25/2023
Transfer of Assets and Replacement for GA (PDF) 08/25/2023
Transfer of Assets and Replacement for ID, IL, TN (PDF) 08/25/2023
Transfer of Assets and Replacement for IN (PDF) 08/25/2023
Transfer of Assets and Replacement for KS (PDF) 08/25/2023
Transfer of Assets and Replacement for MA (PDF) 08/25/2023
Transfer of Assets and Replacement for MI (PDF) 08/25/2023
Transfer of Assets and Replacement for MN (PDF) 08/25/2023
Transfer of Assets and Replacement for MT (PDF) 08/25/2023
Transfer of Assets and Replacement for NV (PDF) 08/25/2023
Transfer of Assets and Replacement for OK (PDF) 08/25/2023
Transfer of Assets and Replacement for PA (PDF) 08/25/2023
Transfer of Assets and Replacement for RI (PDF) 08/25/2023
Transfer of Assets and Replacement for VA (PDF) 08/25/2023
Transfer of Assets and Replacement for WA (PDF) 08/25/2023
Transfer of Assets and Replacement for WY (PDF) 08/25/2023
Transfer of Assets to Nationwide (PDF) 08/25/2023
PHL-VA-102-NQ Partial Withdrawal (Non-Qualified) (PDF) 08/25/2023
PHL-VA-102-Q Partial Withdrawal (Qualified) (PDF) 08/25/2023
PHL-VA-102-SYS Systematic Withdrawal (Non-Qualified) (PDF) 08/25/2023
PHL-VA-102-SYS-Q Systematic Withdrawal (Qualified) (PDF) 08/25/2023
PHL-VA-104 Change Name or Address Form (PDF) 08/25/2023
PHL-VA-106 Collateral Assignment Form (PDF) 08/25/2023
PHL-VA-108 Change Beneficiary Form (PDF) 08/25/2023
PHL-VA-109 Change of Ownership and Beneficiary Form (PDF) 08/25/2023
PHL-VA-110 EFT Request Form (PDF) 08/25/2023
PHL-VA-112 Third Party Payee Request Form (PDF) 08/25/2023
PHL-VA-113 Contribution Form (PDF) 08/25/2023
PHL-VA-114 Annuity Claimant Statement Form (PDF) 08/25/2023
PHL-VA-114LS Annuity Claimant Statement Form - Lump Sum (PDF) 08/25/2023
PHL-VA-114SC Annuity Claimant Statement Form for Supplemental Contracts (PDF) 08/25/2023
PHL-VA-115 Dollar Cost Averaging Form (PDF) 08/25/2023
PHL-VA-116 One Time and Systematic Fund Transfer Request Form (PDF) 08/25/2023
PHL-VA-117 Interest Sweep Request Form (PDF) 08/25/2023
PHL-VA-118 New Investment Allocation and Rebalancing Form (PDF) 08/25/2023
PHL-VA-120 Annuitization - Settlement Request Form (PDF) 08/25/2023
PHL-VA-120-1 Annuitization - Settlement Request Form Non 403(b) (PDF) 08/25/2023
PHL-VA-121 Authorization to Transfer Funds Form (PDF) 08/25/2023
PHL-VA-122 Advisor Authorization Agreement (PDF) 08/25/2023
PHL-VA-123 Due Diligence Supplement (PDF) 08/25/2023
PHL-VA-125 Suitability Form (PDF) 08/25/2023
PHL-VA-126-72Q Periodic Payment Enrollment Form (Non-Qualified) (PDF) 08/25/2023
PHL-VA-126-72T Periodic Payment Enrollment Form (Qualified) (PDF) 08/25/2023
PHL-VA-151 Advisor Fee Instructions (PDF) 08/25/2023
1035 Exchange/Rollover/Transfer Form Addendum (PDF) 08/25/2023
5 Year Delayed Income Surrender Request (PDF) 08/25/2023
5 Year Delayed Income Surrender Request (PDF) 08/25/2023
Acord 1035 Exchange Rollover Transfer Form Addendum (PDF) 08/25/2023
Acord 1035 Exchange Rollover Transfer Form Addendum (PDF) 08/25/2023
Acord 1035 Exchange Rollover Transfer Form Addendum Beneficial Owner (PDF) 08/25/2023
Acord 1035 Exchange Rollover Transfer Form Addendum Beneficial Owner  (PDF) 08/25/2023
Additional Beneficiaries Form (PDF) 08/25/2023
Additional Beneficiaries Form (PDF) 08/25/2023
Advisor Authorization Agreement (PDF) 08/25/2023
Advisor Authorization Agreement (PDF) 08/25/2023
Advisor Fee Instructions (PDF) 08/25/2023
Advisor Fee Instructions (PDF) 08/25/2023
Annuity Beneficiary Claim Form (PDF) 08/25/2023
Annuity Beneficiary Claim Form (PDF) 08/25/2023
Assignment of Annuity Contract as Collateral (PDF) 08/25/2023
Assignment of Annuity Contract as Collateral (PDF) 08/25/2023
Beneficial Owner Life Expectancy Distribution Administration Form (PDF) 08/25/2023
Beneficial Owner Life Expectancy Distribution Administration Form (PDF) 08/25/2023
Beneficiary Change Request (PDF) 08/25/2023
Beneficiary Change Request (PDF) 08/25/2023
Beneficiary Change Request (PDF) 08/25/2023
Beneficiary Claim Form (PDF) 08/25/2023
Certification of Trust (PDF) 08/25/2023
Certification of Trust (PDF) 08/25/2023
Chronically Ill or Disabled Individual Physician Certification Form (PDF) 08/25/2023
Chronically Ill or Disabled Individual Physician Certification Form (PDF) 08/25/2023
Contract Change Request and Medical Questionnaire (PDF) 08/25/2023
Contract Change Request and Medical Questionnaire (PDF) 08/25/2023
Contract Owner Withdrawal Form (PDF) 08/25/2023
Contract Owner Withdrawal Form (PDF) 08/25/2023
Custodial Owner and Account Change Form (PDF) 08/25/2023
Custodial Owner and Account Change Form (PDF) 08/25/2023
Custom Choice Request (PDF) 08/25/2023
Custom Choice Request (PDF) 08/25/2023
Deferred Annuitization Election Form (PDF) 08/25/2023
Deferred Annuitization Election Form (PDF) 08/25/2023
Designation of Restricted Beneficiary for Immediate Annuity (PDF) 08/25/2023
Designation of Restricted Beneficiary for Immediate Annuity (PDF) 08/25/2023
Fund Transfer and Allocation Request (PDF) 08/25/2023
Fund Transfer and Allocation Request (PDF) 08/25/2023
Immediate Annuity Owner Change Request (PDF) 08/25/2023
Immediate Annuity Owner Change Request Form (PDF) 08/25/2023
Immediate Annuity Payee Administrative Form (PDF) 08/25/2023
Immediate Annuity Payee Administrative Form (PDF) 08/25/2023
Internal Transfer Disclosure Form (PDF) 08/25/2023
Internal Transfer Disclosure Form (PDF) 08/25/2023
Nationwide Advisory Income Liquidity Withdrawal Request (PDF) 08/25/2023
Nationwide Advisory Income Liquidity Withdrawal Request (PDF) 08/25/2023
Nationwide Advisory Retirement Income Annuity Guaranteed Lifetime Withdrawal Benefit Administrative Form (PDF) 08/25/2023
Nationwide Advisory Retirement Income Annuity Guaranteed Lifetime Withdrawal Benefit Administrative Form (PDF) 08/25/2023
Nationwide Insurance Only Producer Non-Solicitation Form (PDF) 08/25/2023
Nationwide Insurance Only Producer Non-Solicitation Form (PDF) 08/25/2023
Non-Lifetime Withdrawal Form (PDF) 08/25/2023
Non-Lifetime Withdrawal Form (PDF) 08/25/2023
Payout Beneficiary Claim Form (PDF) 08/25/2023
Payout Beneficiary Claim Form (PDF) 08/25/2023
Payout Beneficiary Claim Form (PDF) 08/25/2023
Producer Information Form (PDF) 08/25/2023
Producer Information Form (PDF) 08/25/2023
Qualified Birth and Adoption Distribution Repayment Form (PDF) 08/25/2023
Qualified Birth and Adoption Distribution Repayment Form (PDF) 08/25/2023
Release of Collateral Assignment (PDF) 08/25/2023
Release of Collateral Assignment (PDF) 08/25/2023
Required Minimum Distribution (RMD) Request Form (PDF) 08/25/2023
Required Minimum Distribution (RMD) Request Form (PDF) 08/25/2023
Restriction of Beneficiary Options (PDF) 08/25/2023
Restriction of Beneficiary Options (PDF) 08/25/2023
Transfer of Assets (PDF) 08/25/2023
Transfer of Assets (PDF) 08/25/2023
IRS W-4P Form (PDF) 01/27/2023
IRS W-4P Form (PDF) 01/27/2023
IRS W-4P Form (PDF) 01/27/2023
IRS W-4P Form (PDF) 01/27/2023

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