North American Pension Services, LLC

Brokerage Accounts

Request Forms

Company Name:

Contact Name:

Phone Number:

Fax:

Email:

Shipping Address:

Please send me the following forms:
(Check all that are needed):

Life Insurance Forms:

W-9 Request for Taxpayer ID Number and Certification
Pre-Authorized Check Payment
Change of Beneficiary
Request for Payment of Cash Surrender
Change of Name
Policy Loan Agreement
Proof of Death Statement
Proof of Disability Statement
Request for Consideration of Reinstatement
Change of Ownership

Health Insurance Forms:

Pre-Authorized Check Payment
Change of Name
Proof of Death Statement
Proof of Disability Statement
Request for Consideration of Reinstatement

Disability Insurance Forms:

Pre-Authorized Check Payment
Change of Name
Proof of Death Statement
Proof of Disability Statement
Request for Consideration of Reinstatement
Change of Ownership

IRA Forms:

Service Request Form
W-9 Request for Taxpayer ID Number and Certification
Pre-Authorized Check Payment
Change of Beneficiary
Request for Payment of Cash Surrender
Change of Name
Proof of Death Statement
Change of Ownership

401(k), Pension Services, Profit Sharing and SEP Participant Forms:

Termination Paperwork
     Date of Termination:
Loan Request
     Amount of Loan Requested:
Hardship Withdrawal Request
Change of Beneficiary
Change of Participant Data
     Data Field to be Changed:

Any Additional Comments or Questions:

North American
Pension Services, LLC
2542 South Rochester Road
Rochester Hills, MI
48307-3817 USA
Phone: (248) 723-4220
Fax: (248) 723-4224
Email: info@naps-ltd.com

Equitas America, LLC
Branch Office
Securities Broker/Dealer
Member FINRA/SIPC

---------------------