Electronic Funds Transfer Request Form
ELECTRONIC FUNDS TRANSFER REQUEST FORM
CONTACT INFORMATION: Pacific Life Insurance Company P.O. Box 2378 Omaha, NE 68103-2378
Clients: (800) 722-4448 Financial Professionals: (800) 722-2333 Fax: (888) 837-8172 RIAs: (833) 953-1863
CONTACT INFORMATION (for New York only): Pacific Life & Annuity Company P.O. Box 2829 Omaha, NE 68103-2829
Clients & Financial Professionals: (800) 748-6907 Fax: (800) 586-0096
Email: AnnuityService@ Web Site:
ALL OVERNIGHT DELIVERIES: Pacific Life Insurance Company 6750 Mercy Rd, RSD Omaha, NE 68106
Use this form to: ? Add or update bank account information for future withdrawals. ? Update existing delivery instructions for active systematic withdrawals.
1 GENERAL INFORMATION If contract is trust, entity, or custodially-owned, please put the name of the annuitant(s) on the owner line(s).
Owner's Name (First, Middle, Last)
Annuity Contract Number
Joint Owner's Name (First, Middle, Last) Trust/Entity Name
Daytime Telephone Number
( )
2 ELECTRONIC FUNDS TRANSFERS (EFT): Complete this section if you want withdrawals to be electronically transferred to the contract owner's
checking or savings account. If account type is not indicated, the information provided will be processed as a checking account. From the time the withdrawal is processed from your contract to the time the funds are received by your financial institution generally takes 2-3 business days. If the contract is owned by a trust, the bank account must reflect the trust name.
Account Type: Checking Savings Financial Institution Name
Account Owner's Name
Financial Institution ABA Number
Financial Institution Account Number
Do not apply to existing systematic withdrawals
I understand that, unless otherwise indicated above, any active systematic withdrawals will be updated with the Electronic Funds Transfer information provided above.
3 SIGNATURE(S) Both Owners' signatures are required if contract is jointly-owned.
SIGN HERE
Owner's Signature
SIGN HERE
Joint Owner's Signature (if applicable)
mm / dd / yy mm / dd / yy
Pacific Life refers to Pacific Life Insurance Company (Newport Beach, CA) and its affiliates, including Pacific Life & Annuity Company. Pacific Life Insurance Company is the issuer in all states except New York. Pacific Life & Annuity Company is the issuer in New York.
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