Forms

Simply download and complete the fillable form, then print, sign and return it to the address on the form


  Please download Adobe ReaderĀ® to view the forms.

View: Life Insurance forms | Annuity forms | Long Term Care Insurance forms

Life Insurance forms

Address, name and third party changes
Submit address or name changes for yourself or other parties on your policy, or to add, change or delete a third party listed on your policy to receive billing notices (for use with Life Insurance policies only).

Allocation and Transfer Change Form for Index UL Products
Information must be completed and received by the 1st of the month to process allocation changes on the 15th of the month. Available for Index UL products only.

Authorization for third party to receive information
Use when authorizing a third party to receive information about your policy. The authorized person will be required to provide appropriate security verification for any phone requests for information.

Certification of trustee powers 
Required to show signing authority for contracts owned by a Trust for Genworth Life and Annuity Insurance Company, Genworth Life Insurance Company and Genworth Life Insurance Company of New York. 

Collateral Assignment
Use when assigning policy proceeds to cover a loan (i.e. bank loan)

Declaration of attorney-in-fact (for use with Life Insurance and Annuities only)
Required to show signing authority for an Attorney-in-Fact acting under a Power of Attorney for the policy or contract owner. For use with Life Insurance and Annuities only.

Duplicate contract authorization
Request a duplicate copy of a lost or destroyed policy or contract.

Electronic funds transfer (EFT) - Premium Renewal
Request automatic withdrawals from your bank account to pay premiums on life or long term care insurance policies, or to update bank account information for policies already drafting premiums.

Health information authorization
An authorization form allowing us to share your health history and related health information with a third party, whom you've designated.

Beneficiary Change Form
Request beneficiary changes on any life insurance policy.  If change of ownership and beneficiary is needed please use the Ownership and beneficiary designation request form applicable for your state (listed below).

Ownership and beneficiary designation request form (Use this form for policies delivered in all states except LA, MD, ME, NH, OH, VA, VT & WA)
Request owner and beneficiary changes on any life insurance policy.

Ownership and beneficiary designation request form (Use this form for policies delivered in LA)
Request owner and beneficiary changes on any life insurance policy.

Ownership and beneficiary designation request form (Use this form for policies delivered in MD)
Request owner and beneficiary changes on any life insurance policy.

Ownership and beneficiary designation request form (Use this form for policies delivered in ME)
Request owner and beneficiary changes on any life insurance policy.

Ownership and beneficiary designation request form (Use this form for policies delivered in NH)
Request owner and beneficiary changes on any life insurance policy.

Ownership and beneficiary designation request form (Use this form for policies delivered in NY)
Request owner and beneficiary changes on any life insurance policy.

Ownership and beneficiary designation request form (Use this form for policies delivered in OH)
Request owner and beneficiary changes on any life insurance policy.

Ownership and beneficiary designation request form (Use this form for policies delivered in VA)
Request owner and beneficiary changes on any life insurance policy.

Ownership and beneficiary designation request form (Use this form for policies delivered in VT)
Request owner and beneficiary changes on any life insurance policy.

Ownership and beneficiary designation request form (Use this form for policies delivered in WA)
Request owner and beneficiary changes on any life insurance policy.

Minnesota Questionnaire
A completed supplement is required if a beneficiary change request is received AND the policy was issued within the past 4 years AND the new proposed beneficiary is anyone other than a family member AND any of the following are true:

  • The existing owner is a MN resident
  • The new beneficiary is a MN resident (including the viatical company is a resident company)
  • Any assignee is a MN resident or company
  • The policy was issued in MN

Release of Collateral Assignment
Use when assignment of policy is relinquished or released

Surrender, loan or withdrawal authorization
Used to request a loan or withdrawal on your life insurance policy. Also used to request a full surrender of a life insurance policy. For annuities, please use either the Fixed annuities withdrawal authorization form or the Variable annuities withdrawal authorization form. This form is used for Life Insurance Policies only.

Loan authorization for life insurance
Use to request a loan on your life insurance policy.

Linked Benefits - Total Living Coverage (TLC) Sample Policy (California Only)
This sample copy of Genworth Life Insurance Company's Universal Life Insurance policy is being provided for informational purposes only.  THIS SAMPLE POLICY IS NEITHER A CONTRACT OF INSURANCE NOR AN OFFER TO CONTRACT.

Annuity forms

Address change form for Structured Settlements or Terminal Funding/Pensions

Annuity contract change form (Do not use for Structured Settlements or Terminal Funding/Pensions)
Request ownership, payee or beneficiary changes on your annuity contract. Also update your address, notify us of any name changes, or add a third party to your contract.

Annuitization request for fixed annuities
Use this form to select income payment options and convert your deferred annuity to
irrevocable payments. For fixed annuities only.

Beneficiary change request form - Structured Settlements
Complete a beneficiary change on a Structured Settlement

Certification of trustee powers
Required to show signing authority for contracts owned by a Trust for Genworth Life and Annuity Insurance Company, Genworth Life Insurance Company and Genworth Life Insurance Company of New York.

Declaration of attorney-in-fact 
Required to show signing authority for an Attorney-in-Fact acting under a Power of Attorney for the contract owner. For use with Life Insurance and Annuities only.

Duplicate contract authorization
Request a duplicate copy of a lost or destroyed policy or contract.

Electronic funds transfer (EFT) authorization for direct deposit of annuity payments  
Request annuity payments to be deposited directly into your bank account or to update bank account information for policies or contracts currently having payments deposited via electronic funds transfer.

Fixed annuities required minimum distribution authorization
Request a Required Minimum Distribution from a fixed annuity.

Fixed annuities withdrawal authorization
Request a single withdrawal from a fixed annuity or authorize future transactions to be requested over the telephone by you or an authorized family member.

Fixed Index Annuity Reallocation Request
Use form to reallocate among the available interest Crediting Strategies.

Immediate annuity to long term care funding request for existing immediate annuity contracts
Certify that all or the specified portion of your non-qualified immediate annuity payment will directly fund a LTCI policy.

Income Advance/Early Advance Request Form for immediate annuities
Request an Income Advance or Early Advance on an immediate annuity contract

Restricted beneficiary payout designation for variable annuities
Restrict the payout option for any beneficiary of a variable annuity.

Single premium immediate annuity Income Advance/Early Advance request form
Use this form to exercise the payment advance feature on a single premium immediate annuity.

Systematic or auto interest withdrawal request for fixed annuities
Request a systematic or auto interest withdrawal from a fixed annuity.

Tax withholding for annuity payments
Designate the amount of state and federal taxes you want withheld from your annuity payments.

Variable annuity annuitization request form
Use this form to select income payment options and convert your deferred annuity to
irrevocable payments. For variable annuities only.

Variable annuities required minimum distribution authorization
Request a Required Minimum Distribution from a variable annuity.

Variable annuity systematic withdrawal request
Request systematic withdrawals from a variable annuity contract.

Variable annuity withdrawal authorization
Request a single withdrawal from a variable annuity or authorize future transactions to be requested over the telephone by you or an authorized family member.

Long Term Care Insurance forms

Address, name or third party changes
Submit address or name changes for yourself or other parties on your policy, or to add, change or delete a third party listed on your policy.

Electronic funds transfer (EFT) authorization
Request automatic withdrawals from your bank account to pay premiums on long term care insurance policies, or to update bank account information for policies already drafting premiums. 

Health information authorization
An authorization form allowing us to share your health history and related health information with a third party, whom you've designated. 

Coverage change request form 
This form is used to request benefit changes and/or change the payment frequency on a current long term care insurance (LTCI) policy. 

Long Term Care Insurance request for beneficiary change 
Use this form to change the beneficiary on an existing Long Term Care Insurance policy, that has a Return of Premium Rider.

Deferred annuity to LTCI 1035 transfer authorization
Use this form to authorize an exchange from a non-qualified deferred annuity contract to a Long Term Care Insurance policy 

Immediate annuity to long term care insurance funding request for existing immediate annuity contracts with irrevocable assignment 
Use this form to certify that all or the specified portion of your non-qualified immediate annuity payment will directly fund your LTCI policy. 

Life insurance to LTCI 1035 transfer authorization 
Use this form to authorize an exchange from a non-qualified life insurance policy to a long term care insurance policy.

Manage Your Account Online


Man working on laptop

Change your address, billing info, automate payments and more.

129277 02/14/14