WSA Fraternal Life - Download Forms

Download Forms (Members Only)

The following forms are available for download:

Form:	Use this form to:	Notes:
Request to Change Beneficiary (Insurance)	Change the beneficiary of your certificate	All signatures must be notarized
Request to Change Name of Insured	Change the name of the insured on your certificate	Must provide legal proof of name change as noted on the form
Request to Change Owner	Change the owner of your certificate
Operation/Dismemberment Claim	Request and document Operation and/or Dismemberment benefit claims	Must be completed and signed by the Physician or Surgeon, or: Accompanied by billing information adequate to support claim
Application for Cash Surrender	Request cash surrender of life certificates	Must be signed by the insured and payer/owner

Annuity Disclosure	Describes important facts and features of a WSA deferred annuity Includes interest rates, surrender charges and taxes on withdrawals	Please read this document if you own a WSA deferred annuity or are considering applying for one
Request to Change Beneficiary (Annuity)	Change the beneficiary of your certificate	Signature must be notarized
Request to Change Name of Annuitant	Change the name of the annuitant on your certificate	Must provide legal proof of name change as noted on the form
Annuity Withdrawal Request	Request a withdrawal of funds from an annuity	Must be signed by the owner of the annuity Includes a copy of IRS Form W-4P, which must also be completed

Electronic Funds Transfer (EFT) Authorization	Authorize electronic funds transfer to pay your life premiums, annuity deposits, or mortgage payment to WSA	Include a voided blank check or deposit slip showing your pre-printed routing transit number and bank codes.
Application for Change of Address	Request change of address for certificates and/or payer	Must be signed by the insured and payer/owner

Scholarship Program Application	Includes program requirements and application form	Requires additional documentation Subject to a submission deadline
Continuing Education Application	Includes program requirements and application form	Requires additional documentation Subject to a submission deadline

Terms & Conditions/Liability Waiver	You must sign and return this form prior to participating in any WSA sponsored event.	Requires parent signature for participants under 18 years of age

Privacy Policy

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WSA Fraternal Life is not licensed in all states. Nothing contained herein should be construed as
a solicitation for insurance or annuity products in any state in which WSA Fraternal Life is not licensed.

Click here for a compete list of states in which WSA Fraternal Life is licensed.

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Participation in any WSA Fraternal Life event constitutes agreement to the
Terms and Conditions for Participation in WSA Events