Forms

Form #	Form Name	Description
VL 13535	Account Access Authorization Form	Used to grant account access to individuals as named by the client or to establish a Client Care Center password on the clients account. PDF only.
VL 14945-2	Additional Beneficiary Custodian for Minor Sheet	Used to submit additional designations of beneficiaries who are minors. Must submit with VL 14945 or application or enrollment form. PDF only.
VL 14945-1	Additional Beneficiary Designation Sheet	Used to submit additional beneficiary designations that exceed space allotted on VL 14945 or application forms. Must submit with VL 14945 or application form. PDF only.
VL 15169	Administrative Change Form	Used to submit administrative changes to a client account. Changes include name, SSN, address, telephone, date of birth, NQDA ownership and delivery option election.
VL 14945	Annuity Beneficiary Designation Form	Used to submit annuity beneficiary designations. Spousal signature notarized or witnessed by a Plan Administrator required for ERISA accounts when a non-spouse is designated as primary beneficiary for more than the allowable percentage under the plan.
VL 23015	Certification of Trust Document and Trustee Powers	The form is required when submitting nonqualified applications where the ownership is a Trust. The form will also be required for subsequent NQDA ownership changes where the new owner is a Trust.
VL 23547	Entity Client Account Form	Used and submitted with every Entity, Trust, or any Non-Individual Organization application for VFA and VALIC and VALIC Transfer Rollover Exchange, except VALIC Group Enrollments.
VL 100	Fixed Annuity Service Request	Used to submit administrative changes to a client account. Changes include beneficiary change, address, name and duplicate contract request.
VL 18546	Forms Usage Guide for Independent Channel Partners	Used to describe the forms needed to complete transactions involving External Broker Dealers selling VALIC products.
VL 19725-457	Pension Protection Act of 2006 and HEART Act of 2008 - 457b	Use to provide additional information for distributions for - military reservists called to active duty, health, long-term care or accident insurance for retired public safety officers, or hardship or UEWs for certain beneficiaries of 457 plans
VL 23547-1	Supplimental Entity Client Account Form	Used to submit additional Trust Donors Trustees or managers and beneficiaries that exceed space allotted on VL 23547 Entity Client Account Form. Must submit with VL 23547.
VL 897	Power of Attorney Affidavit	Used when a Power of Attorney related request is being made. This form is used with all VALIC products.
VL 22415	Profile and Inside Edge Beneficiary Change Form	Used to submit beneficiary designations changes for Profile or Inside Edge Accounts only.

Form #	Form Name	Description
VL 6730	Bank Deposit Agreement	Used by a client to authorize VALIC to transfer funds to a bank account as specified by the client. PDF only.
VL 250	Fixed Annuity Annuitization Request	Used to select the type, annuity benefit, and payment frequency. Note- once selected, the annuity option is irrevocable. This form is used for POWER Index, and Assured Choice (available for Independent Channel Only)
VL 151	Fixed Annuity Minimum Distribution Election Form	Used to initiate the minimum distribution as required by the IRS. This form is used for POWER Index, and Assured Choice which is available in Independent Channel Only.
VL 175	Fixed Annuity Request for Direct Rollover of Funds to VALIC	Used to request a direct Rollover of Funds to a new plan type from another Carrier to VALIC. This form is used for POWER Index, and Assured Choice available for Independent Channel. This form is also used for American Pathway Elite products within Forms Bundling.
VL 163	Fixed Annuity Request for a Partial 1035 Exchange	Used to request a partial withdrawal and assignment of proceeds under section code 1035a. This form is used for POWER Index and Assured Choice - available for Independent Channel.
VL 102FI	Fixed Annuity Request to Transfer Funds to VALIC	Used to transfer money into the same plan type for 1035 exchanges. This form is used for Assured Choice(available in Independent Channel Only), Power Index, and American Pathway Elite products.
VL 217	Fixed Annuity Systematic Premium Preauthorized Debit Form	Used to request an agreement or to change or cancel an existing agreement allowing for the preauthorized debit of systematic premiums. This form is used for POWER Index, and Assured Choice (available for Independent Channel Only)
FA5550DSW	Fixed Annuity Systematic Withdrawal Request	Used to establish a systematic withdrawal of a designated amount and frequency. This form is used for POWER Index and Assured Choice (available in Independent Channel Only).
VL 162	Fixed Annuity Withdrawal Request	Used to request a partial or full cash withdrawal from an annuity contract other than 403(b). Thisa form is used for POWER Index, and Assured Choice (available in Independent Channel Only)
VL 162A	Fixed Annuity Withdrawal Request (for 403(b) TSA only)	Used to request a partial or full cash withdrawal from a 403(b) plan only. This form is used for Assured Choice (available in Independent Channel Only)
VL 18546	Forms Usage Guide for Independent Channel Partners	Used to describe the forms needed to complete transactions involving External Broker Dealers selling VALIC products.
VL 19725-457	Pension Protection Act of 2006 and HEART Act of 2008 - 457b	Use to provide additional information for distributions for - military reservists called to active duty, health, long-term care or accident insurance for retired public safety officers, or hardship or UEWs for certain beneficiaries of 457 plans
VL 897	Power of Attorney Affidavit	Used when a Power of Attorney related request is being made. This form is used with all VALIC products.
VL 316-Roth	Roth IRA Acknowledgment	Used to request an internal Roth IRA conversion of an existing account for American Pathway Elite 4 and 7.
VL 12837	VALIC Unforeseeable Emergency Withdrawal Form	Used to make a withdrawal of funds from 457 plans for unforeseeable emergencies.
VL 22551	1035 Exchange In Form	Used to initiate a Section 1035 Exchange In from an outside carrier to a VALIC account. Send forms directly to Home office for processing. Home office will obtain signoff on suitability from Regional Compliance Analyst.
VL 6201	Annuity Benefits Form	Used to select a Payout option (payment frequency and method) when annuitizing a clients account.
VL 8725	Cash Distribution Form	Used to initiate distribution of a partial withdrawal, maximum withdrawal or full surrender.
VL 995	Death Claim Form	Used by a beneficiary to claim proceeds from a participants account after death.
VL 9006	Internal Combination Rollover Form	Used to request account combination (different group,plan,subgroup to one account) or internal rollover from one VALIC account to another. For product exchanges use VL9034. Minimum Distribution required prior to rollover if client has attained age 70.5.
VL 5320-MAINT	Maintenance Distribution Form	Used for changes to an existing periodic payment associated with a Required Minimum Distribution (RMD) only.
VL 5320	Minimum Distribution Form	Used to initiate the minimum distribution for group sponsored plans clients only as required by the IRS.
VL 5320-EZ	Minimum Distribution Form - Easy	Used for RMD set ups for group sponsored plans only clients where VALIC calculated, pro-rata, multi-year automatic recurring payments. Use RMD Maintenance Form for making changes to an existing RMD. Use Beneficiary Distribution form for beneficiary distributions. Do not use this form for IRA plans.
VL 5320-IRA	Minimum Distribution Form - IRA	Used for RMD set ups for IRA only clients where participant calculates RMD payment, prior year payments, non pro-rata fund selection, joint life expectancy calculation, reinvestment into an existing nonqualified deferred annuity. Use RMD Maintenance Form for making changes to an existing RMD. Use Beneficiary Distribution form for beneficiary distributions. Do not use this form for group sponsored plans.
VL 5320-IRA-EZ	Minimum Distribution Form - IRA Easy	Used for RMD set ups for IRA only clients where VALIC calculated, pro-rata, multi-year automatic recurring payments. Use RMD Maintenance Form for making changes to an existing RMD. Use Beneficiary Distribution form for beneficiary distributions. Do not use this form for group sponsored plans.
VC 26126	NAIC Buyers Guide for Deferred Annuities - Multi States	Used to assist clients in understanding Fixed and Fixed Index Annuities in the following states AL AK AR AZ CO FL GA HI IA ID KY ME MO MT NV NJ NM NC OH OK OR RI SC UT WI and WV. Also required in AL, CO, FL, GA, IA, ME, MO, NH, OH, RI, TX, WI, and WV for Variable Annuities. Must be provided to clients at time of application for the following plan types only IRA, Roth IRA, SEP, Simple IRA and NQDA. Use appropriate guide based on client's state of residence. New Hampshire requires the NAIC buyers guide effective 4/30/2018 with 60 day implementation extension period to 6/30/2018.
VL 11411	Portfolio Director Investment Options	Used to provide additional fund selection space as an addendum to Application, Enrollment, Internal Combination or Rollover and Combined Enrollment or Exchange forms. PDF only.
VL 28668	Qualified Charitable Distribution Supplemental Form	Used when the client has an IRA account and wants to send distribution payments to a qualified 501(c)(3) organization that is eligible to receive tax deductible contributions. Must be used with another VALIC distribution form.
VL 8715	Record of Additional Deposit	Used to transmit an additional contribution for a client and for providing the client with a receipt. Complete only as needed.
VL 25190	Record of Contribtuion	Used by the Independent Channel to transmit an additional contribution for a client and for providing the client with a receipt. Complete only as needed.
VL 25031	Request to Transfer NQDA or Non-insurance Funds to VALIC	Used exclusively by external broker-dealers to liquidate Nonqualified or Non-Insurance accounts and transfer funds to VALIC.
VL 8725-C SONJ	State of New Jersey (SONJ) Cash Distribution Form	Used to initiate distribution of a partial withdrawal, maximum withdrawal or full surrender.
VL 20795	Systematic Withdrawal Form	Used to establish a systematic withdrawal of a designated amount, designated number of years or substantially equal payments. Version 10-2002 includes the Fixed Interest Only option feature and allows for fund selection. Use form VL 20795-LB if the account has a living benefit.
VL 20795-LB	Systematic Withdrawal Form - With Living Benefit	Used for accounts with living benefits to establish a systematic withdrawal of the MAWA or a designated amount less than tor equal to the MAWA. This form should only be used for accounts with living benefits. Use form VL 20795 if the account does not have a living benefit.
VL 18484	Transfer-Rollover In For Use with VALIC Independent Channel	Used exclusively by external broker-dealers to transfer-rollover in funds for ALL PLAN TYPES from a client account at another carrier to VALIC.
VL 22140	VALIC Hardship Distribution Form	Used to request withdrawal or distribution for funds for hardship reasons.
VL 600-FA	Change of Ownership	Used to submit an administrative change of ownership to a client account.
VL 23764	In-Plan Roth Direct Rollovers	Used for the following (must be same ER group and Plan )-Roll existing VALIC assets to a designated Roth VALIC acct-Roll existing VALIC assets to a designated acct at another provider-Roll assets from another plan provider to a VALIC designated Roth acct.
VL 23554	Extended Care Rider Claimant Statement	Used with Premiere 5 and 7, Power Index and (Proflex Independent Channel only) products, to provide proof of extended care in order to waive the contracts early withdrawal charge.
VL 23767	Terminal Illness Rider Claimant Statement	Used with Power Index and (Proflex Independent Channel only) products, to provide proof of terminal illness in order to waive the contracts early withdrawal charge.

Form #	Form Name	Description
VL 18484	Transfer-Rollover In For Use with VALIC Independent Channel	Used exclusively by external broker-dealers to transfer-rollover in funds for ALL PLAN TYPES from a client account at another carrier to VALIC.
VL 26991	Inside Edge Individual Fixed Annuity Application	Inside Edge Fixed Annuity Application must accompany the Inside Edge custodial application. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile. Replaces VL 25459.
VL 26991-FL	Inside Edge Individual Fixed Annuity Application - FL	Inside Edge Fixed Annuity Application must accompany the Inside Edge custodial application. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile. Replaces VL 25459 for FLorida only.
VL 26991-NJ	Inside Edge Individual Fixed Annuity Application - NJ	Inside Edge Fixed Annuity Application must accompany the Inside Edge custodial application. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile. Replaces VL 25459 for New Jersey only.
VL 26991-NY	Inside Edge Individual Fixed Annuity Application-NY	Inside Edge Fixed Annuity Application must accompany the Inside Edge custodial application. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile.For use in New York only. Replaces VL 25459 NY only
VL 26991-VA	Inside Edge Individual Fixed Annuity Application - VA	Inside Edge Fixed Annuity Application must accompany the Inside Edge custodial application. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile. Replaces VL 25459-VA.
VL 26991 (406)	VALIC Fixed Annuity-406 Application	VALIC Fixed Annuity-406 application. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile. Replaces VL 25459 (406).
VL 26991-FL (406)	VALIC Fixed Annuity-406 Application-FL	VALIC Fixed Annuity-406 application. For use in Florida only. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile. Replaces VL 25459(406) in Florida Only
VL 26991-NJ (406)	VALIC Fixed Annuity-406 Application - NJ	VALIC Fixed Annuity-406 application. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile. Replaces VL 25459(406) in New Jersey.
VL 26991-NY (406)	VALIC Fixed Annuity-406 Application-NY	VALIC Fixed Annuity-406 Allocation. For use in New York only. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile. Replaces VL 25459 NY only (406)
VL 26991-VA (406)	VALIC Fixed Annuity-406 Application-VA	VALIC Fixed Annuity-406 Allocation. For use in Virginia only. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile. Replaces VL 25459-VA (406).
VL 23765-IC	State of New York Compensation Disclosure - IC	Used when enrolling clients in Group or Individual Annuity products in the state of New York - informing the client regarding VALICs policy of compensating its insurance producers and their role in offering insurance products. Independent Channel.
VL 21719	Inside Edge IRA Custodial Account Application	Inside Edge Mutual Fund Employee enrollment form for IRA enrollment.
SEE REPLACEMENT TAB	See Replacement Tab	See Replacement Tab for access to State Replacement Forms.
VL 259	Fixed Annuity Notice Regarding Standards MediCal Eligibility	Required for all VALIC annuity products (fixed, variable, qualified and nonqualified ) being sold to clients who reside in CA and are 65 years of age or older if the product is being sold on the basis of its treatment under the CA Medi-Cal program.
VL 14131	Model Replacement Form	Used when replacing life insurance products, including annuities and with all new business in the following states. AL-AR-AK-AZ-CO-CT-HI-IA-KY-LA-MD-ME-MO-MS-MT-NC-NE-NH-NJ-NM-OH-OR-RI-SC-SD-TX-UT-VT-WI-WV. Replacement
VL 22059	Sale to Military Personnel Disclosure	This disclosure form is required if the client has answered YES to being an active duty service member of the United States Armed Forces for all individual non-qualified and IRA applications.
VL 22305	Agent Access Authorization Form	Used to grant account access to Agents as named by the client or to establish a Contact Center password on the clients account. PDF only.
VL 22415	Profile and Inside Edge Beneficiary Change Form	Used to submit beneficiary designations changes for Profile or Inside Edge Accounts only.
VL 22583	Investment Advisory Services Authorization Form	Required to establish Investment Advisory Services on a VALIC client account(s).
VL 23303	Affidavit and Indemnification of Custodian for Minors	Used to open an IRA-Roth IRA in the name of a Minor. Affiant agrees to indemnify VALIC, including its agents, employees, successors, and assigns from every claim, demand or suit brought against them.
VL 23431	Client Profile	Used to establish Independent Channel accounts. Must be completed and submitted with every application, VALIC transfer, rollover, exchange, except VALIC group enrollments in a variable product. Distribute form copies as noted in the legend at bottom.
VL 23479	Payroll Deduction IRA Salary Reduction or Term Agreement	Used to authorize a reduction or termination of a salary reduction agreement for Traditional and Roth IRAs.
VL 25031	Request to Transfer NQDA or Non-insurance Funds to VALIC	Used exclusively by external broker-dealers to liquidate Nonqualified or Non-Insurance accounts and transfer funds to VALIC.
VL 25190	Record of Contribtuion	Used by the Independent Channel to transmit an additional contribution for a client and for providing the client with a receipt. Complete only as needed.
VL 26470-A	Florida Annuity Suitability Questionnaire	Required for all Florida transactions when purchasing a fixed annuity product regardless of how it is funded. Signature pages must be signed. Replaces VL 22982-A
VL 26470-B	Florida Disclosure - Comparison of Annuity Contracts	Required for all Florida transactions when purchasing an annuity product and the source of the money is another annuity. Signature pages must be signed. replaces VL 22982-B
VL 28103	Replacement Form for Virginia	Used when replacing life insurance products, including annuities and with all new business in Virginia.
VC 26126	NAIC Buyers Guide for Deferred Annuities - Multi States	Used to assist clients in understanding Fixed and Fixed Index Annuities in the following states AL AK AR AZ CO FL GA HI IA ID KY ME MO MT NV NJ NM NC OH OK OR RI SC UT WI and WV. Also required in AL, CO, FL, GA, IA, ME, MO, NH, OH, RI, TX, WI, and WV for Variable Annuities. Must be provided to clients at time of application for the following plan types only IRA, Roth IRA, SEP, Simple IRA and NQDA. Use appropriate guide based on client's state of residence. New Hampshire requires the NAIC buyers guide effective 4/30/2018 with 60 day implementation extension period to 6/30/2018.
VC 22966	Kentucky Buyers Guide	Used in the state of Kentucky to assist clients in determining their insurance needs and the products related. Must be provided to the client.
VL 22107	Inside Edge 401(a) Custodial Account Enrollment	Inside Edge Mutual Fund Employee Enrollment form for 401(a) enrollment.
VL 3526	Section 403(b) Salary Reduction Agreement - No Roth	Used to authorize a reduction of salary to fund a Section 403(b) plan. SRA
VL 3526-ROTH	Section 403(b) Salary Reduction Agreement - with ROTH	Used to authorize a reduction of salary to fund a Section 403(b) plan with ROTH deferral available.
VL 14118-ROTH	403(b) SRA and 457(b) Def Comp Agree - with ROTH	Used to authorize a salary reduction and deferral of compensation for groups offering both plans to employees with ROTH deferral available.
VL 14118	403(b) Salary Reduction - 457(b) Def Comp Agree - No ROTH	Used to authorize a salary reduction and deferral of compensation for groups offering both plans to employees. Plan must offer both plans to use this form.
VL 21555	Inside Edge Mutual Fund Individual 403(b) Custodial Applicat	Inside Edge Mutual Fund Employee enrollment form for 403(b) enrollment.
VL 21679	Inside Edge Mutual Fund Indiv 403(b) Custodial Acct Agrmnt	Inside Edge Mutual Fund Inidividual 403(b) Custodial Account Agreement. This document must be provided to individual at application.
VL 4546	Authorization to Defer Salary to a 401(k) Plan	Used to authorize a deferral of salary to fund a 401(k) plan.
VL 4546-ROTH	Authorization to Defer Salary to a 401(k) Plan - ROTH	Used to authorize a deferral of salary to fund a 401(k) plan with ROTH deferral available.
VL 21555-TX	Inside Edge Mutual Fund Indiv. 403(b) Custodial App. - Texas	Inside Edge Mutual Fund Employee enrollment form for 403(b) enrollment for use in Texas only.
VL 8495	Deferred Compensation Agreement	Used for a client to defer compensation pursuant to the Employees Deferred Compensation Plan.
VL 8495-ROTH	Deferred Compensation Agreement 457(b) Governmental Plans	Used for a client to defer compensation of a 457(b) Governmental plan pursuant to the Employees Deferred Compensation Plan.
VL 21680	Inside Edge Mutual Fund Indiv. 457(b) Custodial Acct Agrmnt	Inside Edge Mutual Fund Individual 457(b) Custodial Account Agreement. This document must be provided to individuals at application.
VL 21706	Inside Edge Mutual Fund Individual 457(b) Custodial Applicat	Inside Edge Mutual Fund Employee Enrollment form for 457(b) enrollment.
VL 21706-TX	2)Inside Edge Mutual Fund Indiv. 457(b) Custodial App. Texas	Inside Edge Mutual Fund Employee Enrollment form for 457(b)Enrollment for use in Texas only.
VL 26991	4)Inside Edge Individual Fixed Annuity Application	Inside Edge Fixed Annuity Application must accompany the Inside Edge custodial application. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile. Replaces VL 25459.
VL 26991-NJ	4)Inside Edge Individual Fixed Annuity Application	Inside Edge Fixed Annuity Application must accompany the Inside Edge custodial application. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile. Replaces VL 25459 for New Jersey only.
VL 26991-FL	4)Inside Edge Individual Fixed Annuity Application	Inside Edge Fixed Annuity Application must accompany the Inside Edge custodial application. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile. Replaces VL 25459 for FLorida only.
VL 14118	8)403(b) Salary Reduction - 457(b) Def Comp Agree - No ROTH	Used to authorize a salary reduction and deferral of compensation for groups offering both plans to employees. Plan must offer both plans to use this form.
VL 14118-ROTH	81)403(b) SRA and 457(b) Def Comp Agree - with ROTH	Used to authorize a salary reduction and deferral of compensation for groups offering both plans to employees with ROTH deferral available.
VL 21680	3)Inside Edge Mutual Fund Indiv. 457(b) Custodial Acct Agrmnt	Inside Edge Mutual Fund Individual 457(b) Custodial Account Agreement. This document must be provided to individuals at application.
VL 26996	2)1)ProFlex Flexible Premium Deferred Annuity Application	Proflex FLEXPDFA will close for new applications - sales in all states. The product will remain open for certain groups in IL and KS until a replacement product can be determined. Replaces VL 25456
VL 16377	Electronic Contribution Agreement Form	Used to establish electronic fund transfers for IRAs, non qual tax deferred annuities (NQDAs) SEPs.
VL 14118	91)403(b) Salary Reduction - 457(b) Def Comp Agree - No ROTH	Used to authorize a salary reduction and deferral of compensation for groups offering both plans to employees. Plan must offer both plans to use this form.
VL 14118-ROTH	92)403(b) SRA and 457(b) Def Comp Agree - with ROTH	Used to authorize a salary reduction and deferral of compensation for groups offering both plans to employees with ROTH deferral available.
VL 11411	Portfolio Director Investment Options	Used to provide additional fund selection space as an addendum to Application, Enrollment, Internal Combination or Rollover and Combined Enrollment or Exchange forms. PDF only.
VL 10330	Simple 401(k) Salary Reduction Agreement	Used to authorize salary reductions for SIMPLE 401(k) plans. PDF only. You are responsible for distributing copies as noted in the distribution legend at the bottom of the form.
VL 23180	Uniform Disclosure Notice 403(b) Series 1 - IC	Required by the Texas Retirement System. This form must accompany any new K-12 403(b) applications for a Series 1 contract. For Independent Channel use only.
VL 23181	Uniform Disclosure Notice 403(b) Series 5 - IC	Required by the Texas Retirement System. This form must accompany any new K-12 403(b) applications for a Series 5 contract. For Independent Channel use only.
VL 14945-1	Additional Beneficiary Designation Sheet	Used to submit additional beneficiary designations that exceed space allotted on VL 14945 or application forms. Must submit with VL 14945 or application form. PDF only.
VL 7897	Replacement Exchange Disclosure Form for FL	Used only in Florida when replacing life insurance products including annuities funded through values in existing enforce policy with same insurer Instructions on cover page Obtain submit replacement form to expedite processing by redeeming carrier.
VL 10402	Simple IRA Salary Reduction Agreement	Salary Reduction Agreement for SIMPLE IRA plans. PDF only. You are responsible for distributing copies as noted in the distribution legend at the bottom of the form.
VL 12667-NY IC	Replacement Form for New York - NY 10A - Independent Channel	Used exclusively in New York by Independent Channel Broker-Dealers when replacing an individual annuity or other insurance products. Instructions for distribution of copies and materials are on the cover page of the form. Replacement. PDF includes VL 19176 Authorization To Disclose Information - NY Reg 60
VL 12669-NY IC	Replacement Form for New York - NY 10C - Independent Channel	Used exclusively in Ney York by Independent Channel Broker Dealers when replacing an individual annuity or other insurance products. Instructions for distribution of copies and materials are on the cover page of the form. Replacement.
VL 12670-NY IC	New York Disclosure Statement - NY 10B - Independent Channel	Used exclusively in New York by the Independent Channel Broker Dealer when replacing an individual annuity or other insurance products. Instructions for distribution of copies and materials are on the cover page of the form. Replacement.
VL 19176-IC	Authorization To Disclose Information - NY Reg 60	Used exclusively in NY when replacing an individual annuity or othr insurance products to authorize current carrier to release information necessary to complete attached forms pursuant to NY Reg 60. Replacement. PDF includes VL 12667-IC NY Replacement Form for New York - NY 10A
VL 26995	Portfolio Director Group Enrollment Form	Used by Independent Channel to enroll participants in a qualified GROUP contract. Use state specific for FL, NJ, NY and VA. PDF includes Application and Agent Access. The OA is required in all states. Replaces VL 26443.
VL 26995-FL	Portfolio Director Group Enrollment Form - FL	Used by Independent Channel to enroll in a qualified GROUP contract in Florida. Use state specific for NJ, NY and VA. PDF includes Application and Agent Access. The OA is required. Replaces VL 26443-FL.
VL 26995-NJ	Portfolio Director Group Enrollment Form - NJ	Used by Independent Channel to enroll participants in a qualified GROUP contract in New Jersey. PDF includes Application and Agent Access. Replaces VL 26443-NJ
VL 26995-NY	Portfolio Director Group Enrollment Form - NY	Used exclusively by Independent Channel in New York State only to enroll participants in a qualified GROUP contract. Enrollment. PDF includes Owner Acknowledgement and Agent Access forms. Replaces VL 26443-NY
VL 26995-VA	Portfolio Director Group Enrollment Form - VA	Used by Independent Channel to enroll in a qualified GROUP contract in Virginia. PDF includes Application and Agent Access. Replaces VL 26443-VA.

Form #	Form Name	Description
VL 23562	Life Insurance and Annuities Replacement Memorandum	Used in Arkansas for all Individual and Group Annuity contracts when replacing an Individual Fixed Deferred Annuity. Replacement Memorandum must be completed at the point of sale.
VL 14131	Model Replacement Form	Used when replacing life insurance products, including annuities and with all new business in the following states. AL-AR-AK-AZ-CO-CT-HI-IA-KY-LA-MD-ME-MO-MS-MT-NC-NE-NH-NJ-NM-OH-OR-RI-SC-SD-TX-UT-VT-WI-WV. Replacement
VL 12670-NY IC	New York Disclosure Statement - NY 10B - Independent Channel	Used exclusively in New York by the Independent Channel Broker Dealer when replacing an individual annuity or other insurance products. Instructions for distribution of copies and materials are on the cover page of the form. Replacement.
VL 7897	Replacement Exchange Disclosure Form for FL	Used only in Florida when replacing life insurance products including annuities funded through values in existing enforce policy with same insurer Instructions on cover page Obtain submit replacement form to expedite processing by redeeming carrier.
VL 7744	Replacement Form for CA	Used exclusively in California when replacing life insurance products, including annuities. Instructions are on the cover page. Obtain submit replacement form to expedite processing by redeeming carrier.
VL 7859	Replacement Form for DE	Used exclusively in Delaware when replacing life insurance products, including annuities. Instructions are on the cover page. Obtain submit replacement form to expedite processing by redeeming carrier.
VL 8165	Replacement Form for ID	Used exclusively in Idaho when replacing life insurance products, including annuities. Instructions are on the cover page. Obtain and submit replacement form to expedite processing by redeeming carrier.
VL 27110	Replacement Form for IL	Used exclusively in Illinois, when replacing life insurance products, including annuities. Instructions are on the cover page. Obtain and submit replacement form to expedite processing by redeeming carrier.
VL 7814	Replacement Form for IN	Used exclusively in Indiana when replacing life insurance products, including annuities. Instructions are on the cover page. Obtain submit replacement form to expedite processing by redeeming carrier.
VL 14735	Replacement Form for KS	Used exclusively in Kansas when replacing life insurance products, including annuities. Instructions are on the cover page. Obtain submit replacement form to expedite processing by redeeming carrier.
VL 7742	Replacement Form for MA	Used exclusively in Massachusetts when replacing life insurance products, including annuities. Instructions are on the cover page. Obtain and submit replacement form to expedite processing by redeeming carrier.
VL 7818	Replacement Form for MN	Used exclusively in Minnesota when replacing life insurance products, including annuities. Instructions are on the cover page. Obtain submit replacement form to expedite processing by redeeming carrier.
VL 27289	Replacement Form for NV	Used exclusively in Nevada when replacing life insurance products and annuities (other than individual fixed deferred annuities). Instructions on the cover page. Obtain and submit replacement form to expedite processing by redeeming carrier.
VL 14715	Replacement Form for NV	Used exclusively in Nevada when replacing life insurance products, including annuities. Instructions on the cover page. Submit replacement form to expedite processing by redeeming carrier. Include VL 14715-A when replacing a fixed annuity. Replacement.
VL 12667-NY IC	Replacement Form for New York - NY 10A - Independent Channel	Used exclusively in New York by Independent Channel Broker-Dealers when replacing an individual annuity or other insurance products. Instructions for distribution of copies and materials are on the cover page of the form. Replacement. PDF includes VL 19176 Authorization To Disclose Information - NY Reg 60
VL 12669-NY IC	Replacement Form for New York - NY 10C - Independent Channel	Used exclusively in Ney York by Independent Channel Broker Dealers when replacing an individual annuity or other insurance products. Instructions for distribution of copies and materials are on the cover page of the form. Replacement.
VL 7866	Replacement Form for OK	Used exclusively in Oklahoma when replacing life insurance products, including annuities. Instructions are on the cover page. Obtain and submit replacement form to expedite processing by redeeming carrier.
VL 7862	Replacement Form for PA	Used exclusively in Pennsylvania when replacing life insurance products, including annuities. Instructions are on the cover page. Obtain submit replacement form to expedite processing by redeeming carrier.
VL 27111	Replacement Form for TN	Used exclusively in Tennessee when replacing life insurance products, including annuities. Instructions are on the cover page. Obtain and submit replacement form to expedite processing by redeeming carrier.
VL 28103	Replacement Form for Virginia	Used when replacing life insurance products, including annuities and with all new business in Virginia.
VL 8096	Replacement Form for WA	Used exclusively in Washington when replacing life insurance products, including annuities. Instructions are on the cover page. Obtain and submit replacement form to expedite processing by redeeming carrier.
VL 7847	Replacement Form for WY	Used exclusively in Wyoming when replacing life insurance products, including annuities. Instructions are on the cover page. Obtain and submit replacement form to expedite processing by redeeming carrier.
VL 24844	Replacement Notice - Georgia	Used exclusively in Georgia when replacing life insurance products. Instructions are on the cover page. Obtain and submit replacement form to expedite processing by redeeming carrier.

Form #	Form Name	Description
VL 26991	Inside Edge Individual Fixed Annuity Application	Inside Edge Fixed Annuity Application must accompany the Inside Edge custodial application. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile. Replaces VL 25459.
VL 26991-FL	Inside Edge Individual Fixed Annuity Application - FL	Inside Edge Fixed Annuity Application must accompany the Inside Edge custodial application. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile. Replaces VL 25459 for FLorida only.
VL 26991-NJ	Inside Edge Individual Fixed Annuity Application - NJ	Inside Edge Fixed Annuity Application must accompany the Inside Edge custodial application. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile. Replaces VL 25459 for New Jersey only.
VL 26991-NY	Inside Edge Individual Fixed Annuity Application-NY	Inside Edge Fixed Annuity Application must accompany the Inside Edge custodial application. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile.For use in New York only. Replaces VL 25459 NY only
VL 26991-VA	Inside Edge Individual Fixed Annuity Application - VA	Inside Edge Fixed Annuity Application must accompany the Inside Edge custodial application. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile. Replaces VL 25459-VA.
VL 26991 (406)	VALIC Fixed Annuity-406 Application	VALIC Fixed Annuity-406 application. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile. Replaces VL 25459 (406).
VL 26991-FL (406)	VALIC Fixed Annuity-406 Application-FL	VALIC Fixed Annuity-406 application. For use in Florida only. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile. Replaces VL 25459(406) in Florida Only
VL 26991-NJ (406)	VALIC Fixed Annuity-406 Application - NJ	VALIC Fixed Annuity-406 application. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile. Replaces VL 25459(406) in New Jersey.
VL 26991-NY (406)	VALIC Fixed Annuity-406 Application-NY	VALIC Fixed Annuity-406 Allocation. For use in New York only. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile. Replaces VL 25459 NY only (406)
VL 26991-VA (406)	VALIC Fixed Annuity-406 Application-VA	VALIC Fixed Annuity-406 Allocation. For use in Virginia only. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile. Replaces VL 25459-VA (406).
VL 26470-B	Florida Disclosure - Comparison of Annuity Contracts	Required for all Florida transactions when purchasing an annuity product and the source of the money is another annuity. Signature pages must be signed. replaces VL 22982-B
VC 26126	NAIC Buyers Guide for Deferred Annuities - Multi States	Used to assist clients in understanding Fixed and Fixed Index Annuities in the following states AL AK AR AZ CO FL GA HI IA ID KY ME MO MT NV NJ NM NC OH OK OR RI SC UT WI and WV. Also required in AL, CO, FL, GA, IA, ME, MO, NH, OH, RI, TX, WI, and WV for Variable Annuities. Must be provided to clients at time of application for the following plan types only IRA, Roth IRA, SEP, Simple IRA and NQDA. Use appropriate guide based on client's state of residence. New Hampshire requires the NAIC buyers guide effective 4/30/2018 with 60 day implementation extension period to 6/30/2018.
VL 21719	Inside Edge IRA Custodial Account Application	Inside Edge Mutual Fund Employee enrollment form for IRA enrollment.
VL 22583	Investment Advisory Services Authorization Form	Required to establish Investment Advisory Services on a VALIC client account(s).
VL 14131	Model Replacement Form	Used when replacing life insurance products, including annuities and with all new business in the following states. AL-AR-AK-AZ-CO-CT-HI-IA-KY-LA-MD-ME-MO-MS-MT-NC-NE-NH-NJ-NM-OH-OR-RI-SC-SD-TX-UT-VT-WI-WV. Replacement
VL 28103	Replacement Form for Virginia	Used when replacing life insurance products, including annuities and with all new business in Virginia.
VL 25190	Record of Contribtuion	Used by the Independent Channel to transmit an additional contribution for a client and for providing the client with a receipt. Complete only as needed.
VL 25031	Request to Transfer NQDA or Non-insurance Funds to VALIC	Used exclusively by external broker-dealers to liquidate Nonqualified or Non-Insurance accounts and transfer funds to VALIC.
VL 23431	Client Profile	Used to establish Independent Channel accounts. Must be completed and submitted with every application, VALIC transfer, rollover, exchange, except VALIC group enrollments in a variable product. Distribute form copies as noted in the legend at bottom.
VL 23479	Payroll Deduction IRA Salary Reduction or Term Agreement	Used to authorize a reduction or termination of a salary reduction agreement for Traditional and Roth IRAs.
VL 22305	Agent Access Authorization Form	Used to grant account access to Agents as named by the client or to establish a Contact Center password on the clients account. PDF only.
VL 259	Fixed Annuity Notice Regarding Standards MediCal Eligibility	Required for all VALIC annuity products (fixed, variable, qualified and nonqualified ) being sold to clients who reside in CA and are 65 years of age or older if the product is being sold on the basis of its treatment under the CA Medi-Cal program.
VL 22059	Sale to Military Personnel Disclosure	This disclosure form is required if the client has answered YES to being an active duty service member of the United States Armed Forces for all individual non-qualified and IRA applications.
VL 22415	Profile and Inside Edge Beneficiary Change Form	Used to submit beneficiary designations changes for Profile or Inside Edge Accounts only.
VL 23303	Affidavit and Indemnification of Custodian for Minors	Used to open an IRA-Roth IRA in the name of a Minor. Affiant agrees to indemnify VALIC, including its agents, employees, successors, and assigns from every claim, demand or suit brought against them.
VL 26470-A	Florida Annuity Suitability Questionnaire	Required for all Florida transactions when purchasing a fixed annuity product regardless of how it is funded. Signature pages must be signed. Replaces VL 22982-A
VC 22966	Kentucky Buyers Guide	Used in the state of Kentucky to assist clients in determining their insurance needs and the products related. Must be provided to the client.
SEE REPLACEMENT TAB	See Replacement Tab	See Replacement Tab for access to State Replacement Forms.
VL 23765-IC	State of New York Compensation Disclosure - IC	Used when enrolling clients in Group or Individual Annuity products in the state of New York - informing the client regarding VALICs policy of compensating its insurance producers and their role in offering insurance products. Independent Channel.
VL 18484	Transfer-Rollover In For Use with VALIC Independent Channel	Used exclusively by external broker-dealers to transfer-rollover in funds for ALL PLAN TYPES from a client account at another carrier to VALIC.
VL 22107	Inside Edge 401(a) Custodial Account Enrollment	Inside Edge Mutual Fund Employee Enrollment form for 401(a) enrollment.
VL 21555	Inside Edge Mutual Fund Individual 403(b) Custodial Applicat	Inside Edge Mutual Fund Employee enrollment form for 403(b) enrollment.
VL 21679	Inside Edge Mutual Fund Indiv 403(b) Custodial Acct Agrmnt	Inside Edge Mutual Fund Inidividual 403(b) Custodial Account Agreement. This document must be provided to individual at application.
VL 14118	403(b) Salary Reduction - 457(b) Def Comp Agree - No ROTH	Used to authorize a salary reduction and deferral of compensation for groups offering both plans to employees. Plan must offer both plans to use this form.
VL 14118-ROTH	403(b) SRA and 457(b) Def Comp Agree - with ROTH	Used to authorize a salary reduction and deferral of compensation for groups offering both plans to employees with ROTH deferral available.
VL 3526	Section 403(b) Salary Reduction Agreement - No Roth	Used to authorize a reduction of salary to fund a Section 403(b) plan. SRA
VL 3526-ROTH	Section 403(b) Salary Reduction Agreement - with ROTH	Used to authorize a reduction of salary to fund a Section 403(b) plan with ROTH deferral available.
VL 21555-TX	1)Inside Edge Mutual Fund Indiv. 403(b) Custodial App. - Texas	Inside Edge Mutual Fund Employee enrollment form for 403(b) enrollment for use in Texas only.
VL 26991	3)Inside Edge Individual Fixed Annuity Application	Inside Edge Fixed Annuity Application must accompany the Inside Edge custodial application. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile. Replaces VL 25459.
VL 26991-NJ	3)Inside Edge Individual Fixed Annuity Application	Inside Edge Fixed Annuity Application must accompany the Inside Edge custodial application. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile. Replaces VL 25459 for New Jersey only.
VL 26991-FL	3)Inside Edge Individual Fixed Annuity Application	Inside Edge Fixed Annuity Application must accompany the Inside Edge custodial application. PDF includes Application, Owner Acknowledgement, Agent Access and Client Profile. Replaces VL 25459 for FLorida only
VL 21679	2)Inside Edge Mutual Fund Indiv 403(b) Custodial Acct Agrmnt	Inside Edge Mutual Fund Inidividual 403(b) Custodial Account Agreement. This document must be provided to individual at application.
VL 14118	83)403(b) Salary Reduction - 457(b) Def Comp Agree - No ROTH	Used to authorize a salary reduction and deferral of compensation for groups offering both plans to employees. Plan must offer both plans to use this form.
VL 14118-ROTH	84)403(b) SRA and 457(b) Def Comp Agree - with ROTH	Used to authorize a salary reduction and deferral of compensation for groups offering both plans to employees with ROTH deferral available.
VL 4546	Authorization to Defer Salary to a 401(k) Plan	Used to authorize a deferral of salary to fund a 401(k) plan.
VL 4546-ROTH	Authorization to Defer Salary to a 401(k) Plan - ROTH	Used to authorize a deferral of salary to fund a 401(k) plan with ROTH deferral available.
VL 21706	Inside Edge Mutual Fund Individual 457(b) Custodial Applicat	Inside Edge Mutual Fund Employee Enrollment form for 457(b) enrollment.
VL 21680	Inside Edge Mutual Fund Indiv. 457(b) Custodial Acct Agrmnt	Inside Edge Mutual Fund Individual 457(b) Custodial Account Agreement. This document must be provided to individuals at application.
VL 8495	Deferred Compensation Agreement	Used for a client to defer compensation pursuant to the Employees Deferred Compensation Plan.
VL 8495-ROTH	Deferred Compensation Agreement 457(b) Governmental Plans	Used for a client to defer compensation of a 457(b) Governmental plan pursuant to the Employees Deferred Compensation Plan.
VL 21706-TX	1)Inside Edge Mutual Fund Indiv. 457(b) Custodial App. Texas	Inside Edge Mutual Fund Employee Enrollment form for 457(b)Enrollment for use in Texas only.
VL 21680	2)Inside Edge Mutual Fund Indiv. 457(b) Custodial Acct Agrmnt	Inside Edge Mutual Fund Individual 457(b) Custodial Account Agreement. This document must be provided to individuals at application.
VL 14118	8)403(b) Salary Reduction - 457(b) Def Comp Agree - No ROTH	Used to authorize a salary reduction and deferral of compensation for groups offering both plans to employees. Plan must offer both plans to use this form.
VL 14118-ROTH	81)403(b) SRA and 457(b) Def Comp Agree - with ROTH	Used to authorize a salary reduction and deferral of compensation for groups offering both plans to employees with ROTH deferral available.
VL 26995	Portfolio Director Group Enrollment Form	Used by Independent Channel to enroll participants in a qualified GROUP contract. Use state specific for FL, NJ, NY and VA. PDF includes Application and Agent Access. The OA is required in all states. Replaces VL 26443.
VL 14945-1	Additional Beneficiary Designation Sheet	Used to submit additional beneficiary designations that exceed space allotted on VL 14945 or application forms. Must submit with VL 14945 or application form. PDF only.
VL 11411	Portfolio Director Investment Options	Used to provide additional fund selection space as an addendum to Application, Enrollment, Internal Combination or Rollover and Combined Enrollment or Exchange forms. PDF only.
VL 10330	Simple 401(k) Salary Reduction Agreement	Used to authorize salary reductions for SIMPLE 401(k) plans. PDF only. You are responsible for distributing copies as noted in the distribution legend at the bottom of the form.
VL 23180	Uniform Disclosure Notice 403(b) Series 1 - IC	Required by the Texas Retirement System. This form must accompany any new K-12 403(b) applications for a Series 1 contract. For Independent Channel use only.
VL 23181	Uniform Disclosure Notice 403(b) Series 5 - IC	Required by the Texas Retirement System. This form must accompany any new K-12 403(b) applications for a Series 5 contract. For Independent Channel use only.
VL 26995-FL	Portfolio Director Group Enrollment Form - FL	Used by Independent Channel to enroll in a qualified GROUP contract in Florida. Use state specific for NJ, NY and VA. PDF includes Application and Agent Access. The OA is required. Replaces VL 26443-FL.
VL 7897	Replacement Exchange Disclosure Form for FL	Used only in Florida when replacing life insurance products including annuities funded through values in existing enforce policy with same insurer Instructions on cover page Obtain submit replacement form to expedite processing by redeeming carrier.
VL 10402	Simple IRA Salary Reduction Agreement	Salary Reduction Agreement for SIMPLE IRA plans. PDF only. You are responsible for distributing copies as noted in the distribution legend at the bottom of the form.
VL 26995-NJ	Portfolio Director Group Enrollment Form - NJ	Used by Independent Channel to enroll participants in a qualified GROUP contract in New Jersey. PDF includes Application and Agent Access. Replaces VL 26443-NJ
VL 26995-NY	Portfolio Director Group Enrollment Form - NY	Used exclusively by Independent Channel in New York State only to enroll participants in a qualified GROUP contract. Enrollment. PDF includes Owner Acknowledgement and Agent Access forms. Replaces VL 26443-NY
VL 12667-NY IC	Replacement Form for New York - NY 10A - Independent Channel	Used exclusively in New York by Independent Channel Broker-Dealers when replacing an individual annuity or other insurance products. Instructions for distribution of copies and materials are on the cover page of the form. Replacement. PDF includes VL 19176 Authorization To Disclose Information - NY Reg 60
VL 12669-NY IC	Replacement Form for New York - NY 10C - Independent Channel	Used exclusively in Ney York by Independent Channel Broker Dealers when replacing an individual annuity or other insurance products. Instructions for distribution of copies and materials are on the cover page of the form. Replacement.
VL 12670-NY IC	New York Disclosure Statement - NY 10B - Independent Channel	Used exclusively in New York by the Independent Channel Broker Dealer when replacing an individual annuity or other insurance products
VL 26995-VA	Portfolio Director Group Enrollment Form - VA	Used by Independent Channel to enroll in a qualified GROUP contract in Virginia. PDF includes Application and Agent Access. Replaces VL 26443-VA.
VL 26996	ProFlex Flexible Premium Deferred Annuity Application	Proflex FLEXPDFA will close for new applications - sales in all states. The product will remain open for certain groups in IL and KS until a replacement product can be determined. Replaces VL 25456
VL 16377	Electronic Contribution Agreement Form	Used to establish electronic fund transfers for IRAs, non qual tax deferred annuities (NQDAs) SEPs.

Form #	Form Name	Description
VL 20819	Vendor Loan Supplement	Used to obtain information necessary to determine your eligibility for a loan under a Public Employer 403(b) plan.

Form #	Form Name	Description
VC 24310	Form Annotations for VL 24176 – Portfolio Director Individual Application	Instructions for completing VL 24176.
VC 24311	Form Annotations for VL 23708 – Portfolio Director Owner Acknowledgement	Instructions for completing VL 23708.
VC 24312	Form Annotations for VL 22305 - Agent Access Authorization	Instructions for completing VL 22305.
VC 24313	Form Annotations for VL 22711 – Portfolio Director NQDA Application	Instructions for completing VL 22711.
VC 24314	Form Annotations for VL 18484 - Transfer/Rollover In	Instructions for completing VL 18484.

Form #	Form Name	Description
VL 26992	Portfolio Director Group Master Application	Used by Independent Channel to establish New PD Groups Used with Qual and NQDA plans. Form states that the Multi-Year Enhanced Fixed Opt may not be avail in all states and has other disclosures required for an MYO. Use state specific form in MD, NY or VA. Replaces VL 26442.
VL 26992-NY	Portfolio Director Group Master Application - NY	Used only by Indep Chan to estab New PD Groups in NY. This form is for use with Qualified and NQDA plans. Form has disclosures required for MYO. Independent Channel. Replaces VL 26442-NY.
VL 26992-VA	Portfolio Director Group Master Application - VA	Used only by Indep Chan to estab New PD Groups in VA. This form is for use with Qualified and NQDA plans. Form has disclosures required for MYO. Independent Channel. Replaces VL 26442-VA.
VL 15282	Administrative Services Agreement	Used to establish an administrative service arrangement for 457 Deferred Compensation plans. PDF only.
VL 10421	Agreement Regarding Capital Transfer of Assets	Used exclusively when the Plan Sponsor intends to -employer direct- assets from their former record keeper to VALIC. PDF only. Must provide VALIC with the most current executed plan document, adoption agreement if applicable and all amendments.
VL 18546	Forms Usage Guide for Independent Channel Partners	Used to describe the forms needed to complete transactions involving External Broker Dealers selling VALIC products.
VL 15280-IC	Group Information Sheet - Independent Channel	Used to provide all necessary group related information (payroll contacts, payroll dates, group name address, telephone, etc). For use in the Independent Channel Only. PDF only.
VL 15281	Information for Plan Fiduciary	Used in ERISA covered plans to provide disclosure to the Plan Fiduciary for Agent related compensation.
VL 17584	Service Provider Agreement	Used for new groups coming into VALIC requesting basic administration services and other optional services. Available as PDF only.
VL 26992-MD	Portfolio Director Group Master Application IC - Maryland	Used only by Indep Chan to estab New PD Groups in MD. This form is for use with Qualified and NQDA plans. Form has disclosures required for MYO. Independent Channel. Replaces VL 26442-MD in Maryland Only.
VL 26992-CHOICE	Portfolio Director Choice Group Master Application	Used only by Indep Chan to estab New PD Choice Groups. This form is used with Qual and NQDA plans. Form clearly states the Multi-Yr Enhanced Fixed Opt may not be avail in all states and has other discl reqd for an MYO. Use state spec app for MD, NY or VA. Replaces VL 26442 CHOICE.
VL 26992-MD CHOICE	Portfolio Director Choice Group Master Application - MD	Used only by Indep Chan to estab New PD Groups in MD. This form is for use with Qualified and NQDA plans. Form has disclosures required for MYO. Independent Channel. Replaces VL 26442-MD CHOICE in Maryland Only
VL 26992-NY CH	Portfolio Director Choice Group Master Application - NY	Used only by Indep Chan to estab New PD Choice Groups in NY. This form is for use with Qualified and NQDA plans. Form has disclosures required for MYO. Independent Channel. Replaces VL 26442-NY Choice
VL 26992-VA CH	Portfolio Director Choice Group Master Application - VA	Used only by Indep Chan to estab New PD Groups in VA. This form is for use with Qualified and NQDA plans. Form has disclosures required for MYO. Independent Channel. Replaces VL 26442-VA CHOICE.

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