Forms for Customers and Beneficiaries

Application for Policy Loan (GVULII Loan Form)

Use this form to apply for a policy loan on a GVULII insurance policy. The completed form may be returned via email, fax or mail.

Application for Policy Loan (GVUL Loan Form)

Use this form to apply for a policy loan on a GVUL insurance policy, including Variable Life policies. The completed form may be faxed.

Associated Person’s Information (FR3025)

This form is required when ownership is changed to a non-natural entity (corp, partnership, trust, etc.) on a Variable Annuity or Variable Life product.

Automatic Account Value Transfer/Rebalancing Form

Use this form for account value transfers/rebalancing.

Automatic Account Value Transfer/Rebalancing Form - GVUL

Automatic Account Value Transfer/Rebalancing Form - GVULII

Certificate Change Form (GVULII)

Use this form to make changes in the following states: AL, AZ, AR, CO, DE, DC, FL, GA, HI, ID, IA, KS, KY, MA, MI, NE, NY, ND, OK, OR, PA, RI, SC, SD, TX, WV, WI, WY

Use this form to make changes in the following states: AK, CA, CT, IL IN, LA, ME, MD, MN, MS, MO, MT, NV, NH NJ, NM, NC, OH, TN, UT, VT, VA, WA

Certificate of Foreign Status of Beneficial Owner - Individuals

This form should accompany any disbursement request where the contract is owned by an individual and the address is foreign.

Certificate of Status of Beneficial Owner for United States Tax Withholding and Reporting (Entities)

This form should accompany any disbursement request where the contract is owned by an entity, inclusive of trusts, and the address is foreign.

Fund Transfer Request Form

This form should be used to transfer Account Value between Separate Account Divisions and the Guaranteed Principal Account (GPA).

Fund Transfer Request Form - GVUL

Fund Transfer Request Form - GVULII

Fund Transfer Request Form - SL6

Fund Transfer Request Form - SL9

Fund Transfer Request Form - SL10

Future Net Premium Allocation Change Form

This form should be used to change your allocation of future net premiums among Separate Account Divisions and the Guaranteed Principal Account (GPA).

Future Net Premium Allocation Change Form - GVUL

Future Net Premium Allocation Change Form - GVULII

Future Net Premium Allocation Change Form - SL6

Future Net Premium Allocation Change Form - SL9

Future Net Premium Allocation Change Form - SL10

GUL-GVUL Premium Election Form

This premium election form should be used to make additional contributions to your policy.

Partial Withdrawal (GVULII)

This form should be used to request a partial withdraw from your GVULII policy.

Partial Withdrawal Request - GVUL

This form should be used to request a partial withdraw from your GVUL policy.

Pre-Authorized Check - PAC - Premium Payment Service

Use this form to have premiums automatically deducted from your bank account, change bank name or account of an existing draft. May be faxed.

Request for Taxpayer Identification Number and Certification

This form will certify your Social Security number with MassMutual.

Service Request - Executive Benefits

Use this form for: Changes to Automatic Premium Loans; Face Amount Decrease; Name Changes; Changes of Address; Death Benefit Option Changes.

Or use the form to make any changes listed in the description.

Additional Feature Termination Reset Forms

Use this tool to access service forms to add or terminate certain product features on an Annuity contract.

Annuity Beneficiary Change Request

Use this form to change the Beneficiary on an existing MassMutual annuity contract.

Annuity Contract Change Request Forms

Use this tool to access services forms to change your name, beneficiary, ownership, annuitant and/or premium payor on an Annuity Contract.

Assignment of Annuity Contract as Collateral Forms

Use this tool to access services forms to collaterally assign an Annuity contract to a third party.

Associated Person’s Information (FR3025)

This form is required when ownership is changed to a non-natural entity (corp, partnership, trust, etc.) on a Variable Annuity or Variable Life product.

Automatic Investment Plan AIP

Use this tool to access service forms to establish a new or change/terminate an Automatic Investment Plan that may authorize MassMutual to periodically draw funds for the purpose of making Purchase Payments to an Annuity contract.

Certificate of Foreign Status of Beneficial Owner - Individuals

This form should accompany any disbursement request where the contract is owned by an individual and the address is foreign.

Certificate of Status of Beneficial Owner for United States Tax Withholding and Reporting (Entities)

This form should accompany any disbursement request where the contract is owned by an entity, inclusive of trusts, and the address is foreign.

Deferment of Annuity Date Form

Use this tool to access service forms to change the annuity date on an Annuity contract.

Form FR2057

Form FR2057

Fund Transfers, Future Allocations, Rebalancing & DCA Forms

Use this tool to access service forms to request a fund transfer, make changes to future allocations, elect a Fixed DCA Account or to set-up the following programs: Separate Account Dollar Cost Averaging, Interest Sweep, GPA Liquidation or Rebalancing on an Annuity contract.

Income Payment Information Change Request Form

Use this tool to access service forms to designate payees, update your tax withholding election and/or set up an electronic fund transfer on an Immediate or Payout Annuity contract.

Joint Owner Authorization

Use this form with Jointly Owned contracts to authorize Owners to act individually, on behalf of both Owners, to perform investment/allocation requests and changes to Optional Programs.

Loan - TSA - FR1151

Loan - TSA - FR1151

Partial Withdrawal and Systematic Withdrawal Request Forms

Use this tool to access service forms to request a partial withdrawal or set-up/change/terminate a System Withdrawal program on an Annuity contract.

Required Minimum Distribution RMD Election Forms

Use this tool to access service forms to request a lump sum Required Minimum Distributions and to elect the Systematic Withdrawal Program for automatic Required Minimum Distribution elections on an Annuity contract.

Single Premium Immediate Annuities (SPIA) Period Certain Change Request Forms

Use this tool to access service forms to change the period certain guaranteed period on an Annuity contract. This feature only applies to period certain contracts, not period certain with life.

Subsequent Payment Remittance Forms

Use this tool to access service forms to submit an additional or subsequent payment to an Annuity contract.

MassMutual IRA Additional Contribution Investment Selection Form

Use this form to submit an additional payment (via check) for your MassMutual IRA as well as designate the allocation of your additional payment into a specific fund(s). The IRA Contribution Guide can be used as a basic reference for considering contributions to your MassMutual IRA. (NOTE: The minimum to open a fund is $100.)

MassMutual IRA Tax Withholding Election Form

Use this form to change your federal and /or state tax withholding election for periodic distributions from your MassMutual IRA (Traditional IRA, Rollover IRA, ROTH IRA).

Billing Option Authorization

Use this form to authorize distribution of group list bill.

Change Request

This form can be used to request multiple changes to your policy. Use this form to change or correct the name or address of the owner, beneficiary, payer, insured, or payee; change the premium billing frequency; and add or revoke the Automatic Premium Loan (APL) or Automatic Application of Dividend provision.

Or use the form to make any changes listed in the description.

Consumer Consent Form

Use this form for Electronic Billing and Payments.

Corporate/Partnership Name Change Request

Use this form for legal name changes of corporations and partnerships. DO NOT USE if the name change is due to a merger or sale of assets, the results of the termination of the partnership interest of any partner, or the creation of a partnership interest in a new partner.

Duplicate Policy Request

Use this form to request a duplicate policy.

Owner & Recipient of Benefits Change Request

Use this form for all Ownership and Recipient of Benefits changes.

• If changing from a corporation to an individual, form FR2057 is also required.

• If changing from an LLP/LLC to an individual, form F7833 is also required.

• If changing from a trust to an individual, form F6734/F6734NY is also required.

Pre-Authorized Check (PAC) Premium Payment Service

Use this form to have premiums automatically deducted from your bank account or to make changes to an existing PAC account.

Or use the form to make any changes listed in the description.

Annuitants Beneficiary Form

Use this form to indicate your primary and secondary beneficiaries for your pension annuity. Please mail back to: Pension Risk Transfer B245 - MassMutual 1295 State St. Springfield, MA 01101-0001

Citizen Statement Packet

Use this packet to declare your citizenship or after retirement if your U.S. citizenship status changes to ensure your pension annuity disbursements are taxed correctly. Please mail back to: Pension Risk Transfer B245 - MassMutual 1295 State St. Springfield, MA 01101-0001

CT Withholding Certificate for Pension or Annuity Payments

Use this form to update your Connecticut state withholding for income from your pension annuity. Please mail back to: Pension Risk Transfer B245 - MassMutual 1295 State St. Springfield, MA 01101-0001

Direct Deposit Agreement and Address Form

Use this form to enroll for direct deposit, update direct deposit bank details, or change your address for your pension annuity. Please mail back to: Pension Risk Transfer B245 - MassMutual 1295 State St. Springfield, MA 01101-0001

Or use the form to make any changes listed in the description.

Withholding Certificate for Michigan Pension or Annuity Payments  

Use this form to update your Michigan state withholding for income from your pension annuity. Please mail back to: Pension Risk Transfer B245 - MassMutual 1295 State St. Springfield, MA 01101-0001

Withholding Certificate for Pension or Annuity Payments W4P  

Use this form to update your federal withholding for income from your pension annuity. Please mail back to: Pension Risk Transfer B245 - MassMutual 1295 State St. Springfield, MA 01101-0001