(public)
Life and Annuity Service Forms
Commonly Used Forms

  Address Change - OL4016
Update the address we have on file with your policy.

More info and mailing instructions


  Annuitant Change - OL4004
Update the name of the annuitant we have on file with your policy.

More info and mailing instructions


Authorization to Release Medical Information Forms - OL4076
Authorize release of medical information to Phoenix. Click on the link below to determine which version of the form you need and for additional information.

State variations, more info and mailing instructions


  Beneficiary Designation - OL122
Change or add beneficiaries to your policy.


  Certification and Acknowledgement of Trust Agreement - OL4132
Certify the existence of a trust, as well as current trustees and/or successors.

More info and mailing instructions


  Check-O-Matic Service - OL511
Automatically deposit checks for premium payment, premium deposit fund, or loan repayment.


  Medical Records Request - OL2473
Request that medical records used during the underwriting process be released to the individual whose information is to be released.

More info and mailing instructions


  Name Change - OL3135
Update the name we have on file with your policy.


  Ownership Change - OL2346
Designate a new owner of an individual, business or Trust.


  Request for Surrender of Paid up Additions Rider - OL2001
Designate which rider(s) you wish to surrender.

Variable Products Forms

  Asset Rebalancing Request - OL2855
Readjust investment allocations by shifting money among subaccounts.

More info and mailing instructions


Optional Investment Programs for Variable Annuities
Select an asset rebalancing or a dollar cost averaging investment program for your Phoenix variable annuity.

  OL4061 - for all annuities

More info and mailing instructions


  Request for Systematic Withdrawal - OL2166
Request periodic payments from your annuity contract.

More info and mailing instructions


  Telephone Transfer Privilege Instruction - OL1416
Request telephone services that can be used to transfer contract/policy values.


Variable Annuity Allocation Transfer or Change
Change the status of existing funds, change the allocation schedule or change the current election.

  OL1332A - for all variable annuities

More info and mailing instructions


Variable Annuity Premium Allocation
Use this form to select the subaccount(s) for your premium or loan payment allocation, or choose an asset allocation program.

  OL4032 - for all annuities

More info and mailing instructions


  Variable Universal Life Authorization for Payments, Transfers & Allocations - OL1320I
Includes dollar cost averaging, asset allocation and rebalancing options.

More Forms

  Licensing Questionnaire - HO3295A.


  Disclosure Authorization for Release of Policy/Contract Information - HO5074.


  Certificate of Incumbency - OL4131.


  Block Transfer Form - OL4168.


  Partnership Authorization - OL4363.


  Assignment Release - 520E
Relinquish the right, title and interest of the assignee to Phoenix Life Insurance Company for a specific policy on the life of an insured individual.

More info and mailing instructions


  Collateral Assignment Form - 525
Assign your life insurance policy as collateral for a loan.


  Conversion Request - OL4299
Convert existing term coverage to a permanent life plan.

More info and mailing instructions


  Dividends to Pay Premiums Authorization - OL1236
Apply dividends to pay the balance of premiums becoming due by release of paid-up additions.

More info and mailing instructions


  Financial Transcript Request - OL4266


  Lost Contract Agreement - OL630
Request a new contract if the original has been lost, misplaced or destroyed.

More info and mailing instructions


  Non-Smoker Statement - OL348 6-87
Apply for non-smoker rates or non-smoker and neversmoke risk classification.

More info and mailing instructions


  Policy Change Request - OL180A

  Policy Change Request, Missouri Specific - OL180AMO
Change details on a policy.


  Reduced Paid-Up Policy Request - FA26
Change a premium-paying policy to a paid-up status.

More info and mailing instructions


  Term Conversion Application - OL4776

click to expand or collaspeClick to view the variation required for the following States: AK, FL, ME, NY
Please note: please continue to use the old Term Conversion application in the following state, as the new Term Conversion application has not yet been approved. MA, NC, PR.


  Reinstatement Application - OL4374
Restore a lapsed policy.

click to expand or collaspeClick to view the variation required for the following States: AK, AZ, CA, CT, FL, GA, HI, IN, MD, ME, MI, MN, MO, NC, NE, NJ, NM, NY, OH, OK, OR, PA, PR, SC, TX, UT, VT, WA, WI


  Application for Policy Change Fully Underwritten - OL4695
To change a Policy

click to expand or collaspeClick to view the variation required for the following States: AK, AZ, CA, CT, FL, GA, HI, IN, MA, MD, ME, MN, MO, NC, NE, NM, NY, OH, OK, OR, PA, PR, SC, TX, UT, VA, VT, WA, WI


  Split-Dollar Forms Request/Servicing - OL537
Request split-dollar administrative services: preparing collateral assignment or endorsement, or reporting the annual economic benefit.


35351 6-08

©2001-2014 The Phoenix Companies, Inc.

Insurance and annuities issued by Phoenix Life Insurance Company (PLIC) (East Greenbush, NY), PHL Variable Insurance Company (PHLVIC) (Hartford, CT) and Phoenix Life and Annuity Company (PLAC) (Hartford, CT). PHLVIC is not authorized to conduct business in NY and ME. PLAC is not authorized to conduct business in CA, GA, MA, ME, MN, NH, and NY and not authorized to conduct variable universal life insurance business in ID and LA. The insurers referenced are separate entities and each is responsible only for its own financial condition and contractual obligations.

Securities distributed by 1851 Securities, Inc. (Hartford, CT), member FINRA.

Members of The Phoenix Companies, Inc.

Not all products and services described here are available in all states of the USA.