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How to Fill Out this Form
To use this form, please download the above file, print it using the Adobe Acrobat Reader, complete it and mail it to us at:
Aurora National Life Assurance Company
P O Box 4490
Hartford, CT 06147-4490
Please complete the form in its entirety to avoid delays in processing.
If you are unable to download or print this form, call us at (800) 265-2652, and we will be happy to mail the form to you.
Important Items
You, the Annuitant, or the person to whom benefits are payable, should complete all identifying information, including:
- Contract Number
(Beginning with ``C2" and ending with ``A")
- Social Security Number
- Payee's Full Name
- Payee's Mailing Address or Home Address
- Bank Name
- Bank Address
(Some banks use a centralized processing address; please verify with your bank)
- Bank Phone Number
- Bank Account Number
(Must be in your name)
- Type of Account
(Checking or savings; please verify with your bank)
- Bank Routing Number
(For EFT only: must be 9 digits -- please verify with your bank)
If you are not able to complete this form, a duly appointed representative (guardian, conservator or attorney-in-fact) may arrange for direct deposit or EFT of pension benefits for you. Your representative will need
to complete this form, sign it as your authorized representative (including the appropriate designation) and attach a certified copy of any court-issued document granting him or her authority to act in such
capacity. Please send this form and any attachments to our mailing address shown above.
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