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Change Request Form For Life Policies and/or Annuity Contracts P. O. Box 5068 Clearwater FL 33758-5068 Ph 800-443-9975 ext. 123-6545 Fax 727-299-1765 Email wrlcompensation aegonusa.com Request Type Change of Representative Change of Dealer PLEASE TYPE OR PRINT WITH BLACK INK Policy/Contract Number Date Insured/Annuitant Name Address City State Zip Code PREVIOUS DEALER OF RECORD Dealer Name NEW DEALER OF RECORD Zip New REPRESENTATIVE Last Name Fir.

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