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INSTRUCTIONS - John Hancock Annuities

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INSTRUCTIONS - John Hancock Annuities Powered By Docstoc
					                                                                                                Group Pension Change Form
INSTRUCTIONS
This form is used to make changes to the following information: beneficiary designation, mailing address and legal name of the
participant. No change will be effective unless it is received by John Hancock’s Benefits Administration Office and acknowledged by us.
Note that all information on this form must be printed clearly.
Beneficiary Change Complete Sections 1, 2 and 5. Use this form to change the primary and/or contingent beneficiaries under an
existing contract.
Mailing Address Change Complete Sections 1, 3, and 5. Use this form to change the mailing address for statements and other contract
correspondence.
Legal Name Change Complete Sections 1, 4, and 5. Use this form to change the legal name of a participant of an existing contract
(divorce or marriage).
1. Participant Information
Contractholder: _________________________________ Contract Number: ______________________________________________________-GAC

Certificate Number: ______________________________ Participant Name: __________________________________________________________

Social Security #/TIN: __________________________________ Phone #: (______) _______________________

Street Address: ___________________________________________ City: _____________________State: ________Zip: ____________

2. Change of Beneficiary
No Complex Beneficiaries John Hancock will not accept complex beneficiary designations.
Contingent Percentages Must Equal 100% Percentages must be in whole numbers and equal 100%. If you need additional space,
please attach a letter which is signed and dated by the participant. If you do not indicate percentages, then all contingent beneficiaries
will be split equally.
Update Both Categories If you wish to change your Primary Beneficiaries only, you must re-state any Contingent Beneficiaries currently
on file at John Hancock or those Contingent Beneficiaries will be revoked. By changing your beneficiary designation, either primary or
contingent, your revoke all previous beneficiary designations under the above Certificate and designate the following beneficiary
(beneficiaries) in lieu of those revoked, to receive any death benefit payable under the terms of said Certificate.

New Primary Beneficiary(ies)*:

1. Name: ________________________________________________________Social Security #: ______________________________

Address: _________________________________________________________________________________________________________________
        Street                                                                                              City               State            Zip
Relationship to participant: ______________________________________________Date of Birth: ________________________________________

New Contingent Beneficiary(ies):

1. Name: ________________________________________________________Social Security #: ______________________________

Address: ________________________________________________________________________________________________________________
        Street                                                                                              City               State            Zip
% of Proceeds: ________________________________________ Relationship to participant: _____________________________________________

Date of Birth: _________________________________________

2. Name: ________________________________________________________Social Security #: ______________________________

Address: ________________________________________________________________________________________________________________
        Street                                                                                              City               State            Zip
% of Proceeds: ________________________________________ Relationship to participant: _____________________________________________

Date of Birth: _________________________________________



                 Insurance products are issued by: John Hancock Life Insurance Company (U.S.A.) (not licensed in New York), Boston, MA 02116;
                     John Hancock Life Insurance Company of New York, Valhalla, NY 10595, herein collectively referred to as John Hancock.
                                                                                                  Group Pension Change Form
2. Change of Beneficiary - continued
3. Name: ________________________________________________________Social Security #: ______________________________

Address: ________________________________________________________________________________________________________________
         Street                                                                                              City               State            Zip
% of Proceeds: ________________________________________ Relationship to participant: _____________________________________________

Date of Birth: _________________________________________

*If you are married and the Primary Beneficiary is other than your spouse, the Spousal Consent section below must be
completed.
Spousal Consent

I, ______________________________, hereby acknowledge the effect of and consent to the election made by my spouse to waive payment of his or
her death benefit/annuity. I understand by signing this consent, I may not receive any benefit from the Plan after the death of my spouse.


Signature of Spouse________________________________________________________ Date: _______/_______/___________


Signature of Plan Administrator_______________________________________________ Date: _______/_______/___________

3. Change of address
Please change the address for the participant under the above Certificate to the following:
Street Address: ________________________________________________________________________________________________

City: ______________________________________________________State: _______________________Zip: ___________________

4. Name change
Change is for (check one):

 Participant

 Beneficiary

 Contingent Annuitant under Certificate_____________________________________________________and the above numbered Contract.


Change is due to (check one):

 Marital status has changed from single to married (Attach copy of marriage license)

 Marital status has changed due to a divorce (Attach copy of divorce decree)

 Other :__________________________________________________________________( Attach copy of any court order)

Change From: ________________________________ ________________________________________Date: _____/_____/_______
                               Please Print Prior Name                                   prior Signature


Change To: __________________________________ ________________________________________Date: _____/_____/_______
                               Please Print Prior Name                                   new Signature




                  Insurance products are issued by: John Hancock Life Insurance Company (U.S.A.) (not licensed in New York), Boston, MA 02116;
                      John Hancock Life Insurance Company of New York, Valhalla, NY 10595, herein collectively referred to as John Hancock.
                                                                                            Group Pension Change Form
5. Signatures and authorization
Authorization I request and authorize John Hancock make the above changes to the specified Certificate, and I agree to submit
additional information upon request if such information, in the discretion of John Hancock, is necessary to implement the changes on this
form. I also understand that the instructions on this form are subject to the terms and conditions of the Contract.

Signature of Participant: _____________________________________________________________ Date: _______/_______/___________

Did you remember to...
• Complete all applicable sections of this form and provide phone numbers if we need to contact you?

• Provide a copy of the trust agreement if the designated beneficiary is a trust?

• Include a copy of the participant’s power-of-attorney if this form is signed by a participant’s attorney-in-fact or agent?

• Call John Hancock Annuities toll free at 1-800-624-5155 with any questions about this form?

Contact information
John Hancock                                                                                  Fax: (617) 572-0355
Benefit Administration                                                                        Questions: 1-800-624-5155
P.O. Box 9512
Portsmouth, NH 03802-9512




             Insurance products are issued by: John Hancock Life Insurance Company (U.S.A.) (not licensed in New York), Boston, MA 02116;
                 John Hancock Life Insurance Company of New York, Valhalla, NY 10595, herein collectively referred to as John Hancock.

				
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