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OMNI
®
403(b) PLAN DISBURSEMENT REQUEST FORM
Step 1 of 3: Supply Information
|
Step 2 of 3: Confirm Entries
|
Step 3 of 3: Submission Confirmation
Please supply the information requested below.
Read all agreements on this form before submitting.
Fields having an asterisk notation are required.
Transaction Type:
*
Type:
Death Claim
Disability
Distribution
Exchange
Qualified Domestic Relations Order
Required Minimum Distribution
Rollover
Service Credit
Transfer
The movement of funds from one 403(b) provider to another eligible 403(b) provider under the same Employer's Plan. For more details, please visit our
Transaction Information
page or
contact OMNI
®
.
Employee Information
*
Last Name:
*
First Name:
MI:
Maiden/Former Name:
*
Address:
*
City:
*
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Other
  
*
Zip:
*
Phone:
Alternate Phone:
*
Email:
*
Re-enter Email:
*
SS#:
(9 digits, no dashes or spaces)
*
Date of Birth:
(MM/DD/YYYY)
Service Provider Agent Information:
There is a financial advisor/representative associated with this transaction.
*
Agent Name:
*
Agent Phone:
*
Agent Email:
Agent Fax:
I wish the above named agent to be copied on all e-mail communications sent to the plan participant, including certificate(s) of approval, which may be associated with this transaction.
Distributing Account Information:
Please provide the information for the employer from whose Plan you wish to withdraw funds:
*
Employer State:
*
Employer Name:
This must be your current employer for the transaction to be an Exchange
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Other
[Select State First]
Please provide the following information for the Service Provider who will be distributing (paying out) the funds for this transaction:
*
Service Provider Company:
Alger Funds
Alliance Bernstein
Alliance One
Allianz
Allstate Insurance Co.
American Century
American Fidelity
American Funds/Capital Bank & Trust
American General
American Portfolio Financial
American United Life
Americo
Ameriprise
Ameritas
Annuity Investors Life Ins Co
ASPire
Athene
AVIVA
AXA Accumulator
AXA Equitable
Black Rock
Brighthouse Financial
Brighton Securities
Cadaret Grant & Co
Calvert Group
Charles Schwab
Chemung Canal Trust
Citigroup-Smith Barney
Columbia Mutual
Commonwealth Annuity
Compass Capital
Confidential Brokerage
Confidential Planning
Conseco
Consolidated Financial
CPI Qualified Plan Consultants Inc
David Lerner
Delaware
Diversified
Dreyfus
DWS
Edward Jones
Eschels Financial
Evergreen Funds
Faculty Services
Fidelity & Guaranty Life Insurance
Fidelity Advisors
Fidelity Management Trust
Fiduciary Trust Intl of the South (Franklin)
FirstSun America
Foresters Financial (First Investors)
Franklin Templeton
FTJ Fundchoice
FTJ/L&M Financial
General American
Genworth Financial
Gleaner Life Insurance
GLP &Associates
Great American Financial Resources
Great West
Guardian
Guggenheim
GWN
Hartford Life
Hooker & Holcombe
Horace Mann
Industrial Alliance
Invesco AIM
Jackson National Life
Janus
Jefferson National
John Hancock
JP Morgan
Kades-Margolis
Kemper/Zurich
Knights of Columbus
LA Hertberg Associates
Lincoln Financial/National
Lincoln Investments
Lord Abbett
LPL Corporation
Mainstay
Mass Mutual
Merrill Lynch
Metlife
Metlife of CT
MFS Service Center
Midland National
Minnesota Life
Modern Woodmen
Morgan Stanley/Smith Barney
Mutual Inc.
National Life Group(LSW)
Nationwide
New England Financial
New York Life
NFS
North American Company
Northwestern Mutual
NYS Deferred Comp
Oldham Resources
Oppenheimer
P & A Administrative Services
Pacific Life
Paradigm Equities/MEA
Paul Revere
Pershing
Phoenix Home Life
Pioneer
Plan Member Services
Presidential Life
Prime Plan
Primerica
Principal Life Insurance
Proequities
Protective Life Ins & Annuity Co (PLICO)
Prudential
Putnam
RiverSource
Royal Alliance
Sage Rutty
SaveDaily
Scudder Funds
Security Benefit
SEI
Sgroi Financial
State Farm
Sun Life
Symetra
T. Rowe Price
TD Ameritrade
Tennessee Farmers
The Legend Group
Thrivent Financial for Lutherans
TIAA CREF
TransAmerica
UBS Financial
Union Central Life
Unity Mutual
USAA Life
VALIC
Vanguard Fiduciary Trust
VanKampen
Voya
Voya (CT)
Voya (Opp Plus)
Voya (Reliastar)
Wachovia
Waddell & Reed
Washington National Insurance Company
Wells Fargo
Western National
Wilton Reassurance
Wisconsin Education Association (WEA)
Zurich American Life Insurance Company
If other, please supply company name here:
Account #:
*
Amount Requested:
Receiving Account Information:
Please provide the following information for the Service Provider who will be receiving the funds for this transaction:
*
Service Provider Company:
If other, please supply company name here:
Account #:
Confirmation:
By clicking the button below labled "Continue", I hereby confirm that the information on this form is correct and complete to the best of my knowledge.
*
Re-enter Social Security # to verify:
Additional instructions will appear on the next screen
    
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