The forms below are provided for you to request certain changes or transactions on your certificate. You can download any of the forms directly to your computer. Once you have completed the form you can submit it to:
Member and Agent Services
Gleaner Life Insurance Society
5200 W. U.S. Hwy 223, Adrian, MI 49221.
To protect your personal information, you can also securely submit the completed forms through our file transfer service. Click here for the Secure File Transfer.
Need assistance? Contact Member and Agent Services at 800-992-1894.
| General Service | |
|---|---|
| Use this form to request service on a certificate, including member name changes, address changes, loans on life insurance, annuity withdrawals, automatic required minimum distributions from IRAs, etc. | |
| Use this form to request a settlement on an annuity certificate. | |
| Death Claim | |
|---|---|
| Claim for Death Benefits Notification | Completing this form will notify Gleaner of the death of your loved one. |
| Change of Beneficiary | |
|---|---|
| Change of Beneficiary | This form should be used when submitting a change of beneficiary on a certificate. |
| Separate Beneficiary Designations | This form is to be used with a non-qualified annuity if the annuitant and owner are two separate individuals and unique beneficiary designations are desired. |
| Change of Beneficiary Additional Names | This form should be used in addition to Beneficiary Change Request (437-04 or 437A-08) forms if you require additional space. |
| Change of Ownership | |
|---|---|
| Transfer of Ownership | This form is required to change the owner on any certificate number beginning with 356000 and up. Ownership cannot be changed on tax qualified annuities. Original signature is required. |
| Absolute Assignment | This form is required to change the owner on any certificate number below 356000. Original signature is required. |
| Collateral Assignment | This form is required to assign the certificate as collateral. Original signature and two forms are required. |
| Premium Payment | |
|---|---|
| One Time Check Draft Authorization | Use this form when faxing or emailing a check. The check should be made payable to Gleaner Life Insurance Society for the amount of the required premium. Do not mail the original check if this form has been used. |
| Automatic Withdrawal Authorization | This form is used to establish automatic monthly premium payments from the member's bank account. |
| Miscellaneous | |
|---|---|
| Substitute Form W-9 | Complete and submit this form to Gleaner's Home Office to confirm your correct Social Security number. |