Forms
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| Category | Form Number | Title | Description |
|---|---|---|---|
| Annuity Distribution | 10438 (PDF, 465K) |
Annuity / Settlement Option Withdrawal Service Request | This form is used for: Partial withdrawals and full surrender of Annuities or Settlement Options Instruction Sheet(s): 10438INS (PDF, 803K) |
| Annuity Distribution | 14642 (PDF, 359K) |
Automatic Payout Option | This form is used to: Establish an Automatic Payout Option or to make changes on an existing automatic payout option. Instruction Sheet(s): 14642INS (PDF, 801K) |
| Annuity Distribution | 14643 (PDF, 374K) |
Required Minimum Distribution Request for Ongoing Scheduled Payments | This form is used to: Establish the Required Minimum Distribution payout or to make changes on an existing required minimum distribution payout. Instruction Sheet(s): 14643INS (PDF, 80K) |
| Annuity Distribution | 14804 (PDF, 54K) |
Request for Waiver of Surrender Charges for Health Care Facilities Confinement | This form is used to: Request a waiver of surrender charges due to health care facilities confinement. |
| Annuity Distribution | 24143 (PDF, 166K) |
Certification of Trust | This form is only needed when a contract is owned by a trust. |
| Annuity Distribution | W-4P (PDF, 1.2M) |
Withholding Certificate for Pension or Annuity Payments | Use Form W-4P to tell payers the correct amount of federal income tax to withhold from your payment(s). |
| Annuity Distribution | NC-4P (PDF, 37K) |
Withholding Certificate for Pension or Annuity Payments - NC Department of Revenue | Required for North Carolina residents if they are electing not to have withholding on their distribution. This must be submitted with the distribution request form. |
| Beneficiary Designation | 307B (PDF, 215K) |
Beneficiary Designation – Common | This form is used for: Create a new Beneficiary Designation |
| Billing and Payments | 1698-5 (PDF, 69K) |
403(b) Calculation Worksheet | 403(b) Calculation Worksheet |
| Billing and Payments | 23045A (PDF, 668K) |
Payment Services Request - Direct Payment | Payment Services Request - Direct Payment |
| Billing and Payments | 23045B (PDF, 670K) |
Payment Services Request - Direct Bill | This form is used to: Authorize Thrivent Financial for Lutherans to send your bill to the named person or entity |
| Billing and Payments | 23045C (PDF, 668K) |
Payment Services Request - Group Bill | This form is used to: Authorize Thrivent Financial for Lutherans to send your bill to the named person or entity |
| Billing and Payments | 24815A (PDF, 15K) |
Death Benefit Guarantee Waiver - UL | This form is used to: Request that Thrivent Financial for Lutherans stop mailing notices regarding termination and/or reinstatement of the Extended Death Benefit Guarantee |
| Billing and Payments | 24815B (PDF, 15K) |
Death Benefit Guarantee Waiver - VUL | This form is used to: Request that Thrivent Financial for Lutherans stop mailing notices regarding termination and/or reinstatement of the Enhanced Death Benefit Guarantee |
| Billing and Payments | 5245 (PDF, 123K) |
403(b) Contribution Agreement | This form is used to: Request to remit 403(b) contributions for purchase of an annuity contract or mutual fund shares |
| Billing and Payments | 6568 (PDF, 145K) |
Direct Payment Authorization |
Withdrawals are prepared each month on the withdrawal date you select (1-28) and are routed through the Federal Reserve System to the account owner’s financial institution. One withdrawal is produced for each Thrivent Direct Payment account, and for each withdrawal date selected. Withdrawals returned unhonored due to insufficient funds will automatically be presented a second time to the account owner’s financial institution for payment. Instruction Sheet(s): 6568INS (PDF, 113K) |
| Billing and Payments | V6406 (PDF, 110K) |
Variable Products Allocation Change | This form is used to: Make changes to your premium allocation and/or remit a payment on any of your Variable Products. |
| Death Claim Information | To request a claim form, contact 800-THRIVENT (800-847-4836). As always, your Thrivent Financial representative is also available to answer your questions. |
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| Disability Income Insurance | DI259 (PDF, 107K) |
Disability Income Insurance claim form for all states except ME, NY, MA, NJ and NC | This form is used to: • File a claim under your disability income contract. Complete it immediately upon disability. • Claim benefits under both disability income and life contracts, it is not necessary to complete a separate form for each benefit. Do NOT use this form if your only claim is for waiver on life contracts. Instead, complete the Life Premium Waiver/Disability Waiver Insurance Claim (LF259). Help |
| Disability Income Insurance | DI259A (PDF, 107K) |
Disability Income Insurance claim form for ME, NY, MA, NJ and NC | This form is used to: • File a claim under your disability income contract. Complete it immediately upon disability. • Claim benefits under both disability income and life contracts, it is not necessary to complete a separate form for each benefit. Do NOT use this form if your only claim is for waiver on life contracts. Instead, complete the Life Premium Waiver/Disability Waiver Insurance Claim (LF259A). Help |
| Hospital Confinement/Family Hospital | No claim forms are required. | Send a copy of your itemized hospital bill or the UB04. Include the diagnosis if not on the bill or UB04. |
|
| Life Insurance Distribution | 11090 (PDF, 139K) |
Life Values Distribution | This form is used for: Distribution requests from Life Insurance Contracts. Choose the instruction sheet that corresponds to your requested distribution type. Instruction Sheet(s): 11090C (PDF, 83K) - Complete Surrender 11090P (PDF, 83K) - Partial Surrender (UL/VUL contracts only) 11090L (PDF, 83K) - Loans 11090DR (PDF, 82K) - Dividend Surrender (traditional life contracts only) 11090DC (PDF, 29K) - Dividend Option Change |
| Life Insurance Distribution | 24143 (PDF, 166K) |
Certification of Trust | This form is only needed when a contract is owned by a trust. |
| Life Insurance Premium Waiver | 259A (PDF, 72K) |
Life Premium Waiver/Disability Waiver claim form for Children in ME, NY, MA, NJ and NC | This form is used to: |
| Life Insurance Premium Waiver | 259C (PDF, 72K) |
Life Premium Waiver/Disability Waiver claim form for Children in all states except ME, NY, MA, NJ and NC | This form is used to: File a child’s waiver claim on a life contract. Complete it after four/six (per the contract) consecutive months of total disability. Total disability exists when a child is at least age five and, due to accidental bodily injury or disease, is unable to attend a regular school or a special education facility. Under some contracts the disability must begin after age five. Refer to the contract for specific requirements. Help |
| Life Insurance Premium Waiver | LF259 (PDF, 90K) |
Life Premium Waiver/Disability Waiver claim form for Adults in all states except ME, NY, MA, NJ and NC | This form is used to: File a waiver claim on a life contract. Complete it after four/six (per the contract) consecutive months of total disability. Do not use this form if your only claim is for disability income or both life waiver and disability income. Instead, complete the Disability Income Insurance Claim (DI259). Help |
| Life Insurance Premium Waiver | LF259A (PDF, 90K) |
Life Premium Waiver/Disability Waiver claim form for Adults in ME, NY, MA, NJ and NC | This form is used to: File a waiver claim on a life contract. Complete it after four/six (per the contract) consecutive months of total disability. Do not use this form if your only claim is for disability income or both life waiver and disability income. Instead, complete the Disability Income Insurance Claim (DI259A). Help |
| Long Term Care Insurance | 23057 (Word, 293K) |
Long Term Care Claim Packet for all states except ME, NY, MA, NJ and NC | This form is used to: File a claim for Long Term Care benefits. Complete it once covered care begins. Help |
| Long Term Care Insurance | 23057A (Word, 309K) |
Long Term Care Claim Packet for ME, NY, MA, NJ and NC | This form is used to: File a claim for Long Term Care benefits. Complete it once covered care begins. Help |
| Medicare Supplement Insurance | No claim forms are required. | Most claims are filed electronically through the Medicare carrier. For claims not filed electronically, send the original Explanation of Medicare Benefits (EOMB) and the itemized bill. |
|
| Mutual Funds | 11502 (PDF, 121K) |
Transfer/Direct Rollover/Conversion Request | This form is used to: Process internal and external transfers, direct rollovers and internal conversion of retirement plan accounts. Instruction Sheet(s): 11502INS (PDF, 22K) |
| Mutual Funds | 24143 (PDF, 166K) |
Certification of Trust | This form is only needed when a contract is owned by a trust. |
| Mutual Funds | 6568MF (PDF, 75K) |
Automatic Bank Withdrawal | This form is used to: • Establish bank draft plan (systematic purchase from a financial institution to a mutual fund account) • Change financial institution • Change bank draft plan or • Stop existing bank draft plan Instruction Sheet(s): 6568MFINS (PDF, 16K) |
| Mutual Funds | 9368C (PDF, 367K) |
Automated Payment of a Thrivent Financial/Thrivent Life Insurance Company Product | This form is used to: Establish a systematic payout from a Thrivent Mutual Fund to pay the premium or loan repayment of another Thrivent product via the internal Electronic Payment System. Instruction Sheet(s): 9368CINS (PDF, 18K) |
| Mutual Funds | MF23427 (PDF, 18K) |
Money Market Redemption Options Instructions | This form is used to: Establish the checkwriting option on a money market account. Instruction Sheet(s): MF23427INS (PDF, 18K) |
| Mutual Funds | MF23428 (PDF, 105K) |
Automatic Exchange Plan Instructions | This form is used to: • Establish ongoing automatic/systematic investment purchases from a mutual fund to a different mutual fund account(s) with the same share class, account owners and account type. • Add or change accounts • Add or change draw dates or dollar amounts • Stop existing plan Instruction Sheet(s): MF23428INS (PDF, 18K) |
| Mutual Funds | MF23430 (PDF, 83K) |
Systematic Withdrawal Plan Redemption Option | This form is used to: Establish a systematic or periodic scheduled redemption from most mutual fund accounts ($5,000 minimum account balance to start); funds will be sent to the account owner’s address of record or their personal bank account. This is not intended to establish the annual Required Minimum Distribution (RMD) for IRA/403B accounts. Instruction Sheet(s): MF23430INS (PDF, 18K) |
| Mutual Funds | MF23432 (PDF, 136K) |
Transfer of Ownership Request | This form is used to: Transfer ownership from an existing Thrivent Mutual Fund to a new owner or a new registration type (example: transferring from an individual to a joint tenant, removing the name of a custodian from a UGMA/UTMA when the minor reaches the age of distribution, when gifting dollars to another person or entity). Instruction Sheet(s): MF23432INS (PDF, 18K) |
| Mutual Funds | MF23433 (PDF, 120K) |
Redemption Request | This form is used to: Redeem any amount from a qualified (IRA) or non-qualified mutual fund account. A Medallion Signature Guarantee is required of all owners if redeeming more than $100,000 or to an address/payee other than the address/payee of record. Instruction Sheet(s): MF23433INS (PDF, 23K) |
| Mutual Funds | MF23435 (PDF, 53K) |
Telephone Transactions | This form is used to: Establish the ability to request transactions by telephone. When the telephone option is available, internet transactions will also be available, although limited internet transactions are available for retirement plan accounts. Instruction Sheet(s): MF23435INS (PDF, 14K) |
| Mutual Funds | MF307 (PDF, 82K) |
Mutual Funds Beneficiary Designation | This form is used to: • Designate the beneficiaries of an IRA, 403b or Coverdell account or change designations currently on file. • Any new information provided will replace any beneficiary designations currently on file. Instruction Sheet(s): MF307INS (PDF, 17K) |
| Variable Products | 15771 (PDF, 16K) |
Telephone Transaction Authorization | This form is used to: Elect or revoke telephone transaction authorization on any of your variable products. Telephone transaction authorization authorizes Thrivent to accept and act upon telephone or electronic instructions for certain transactions. Be sure to fill out this form accurately and completely or your request for telephone transaction authorization may be delayed. |
| Variable Products | 15773 (PDF, 56K) |
Subaccount Transfer Selection | This form is used for: One-time, periodic transfer of funds between subaccounts on any of your variable products. Be sure to fill out this form accurately and completely or your request may be delayed. |
| Variable Products | V6406 (PDF, 109K) |
Variable Products Allocation Change/Remittance Request | This form is used to: Make permanent changes to your premium allocation for future payments or make a one-time change with a payment on any of your variable products. Be sure to fill out this form accurately and completely or your request may be delayed. |
Disability Income Insurance
If you are unable to print a form or have any questions, contact your Thrivent Financial claim representative at mail@thrivent.com, attention Disability Income Insurance Claims, or call 800-THRIVENT (800-847-4836) and say "Health Insurance Claim" and then "Initiate a new claim". You will then be asked to provide your social security number. As always, your Thrivent Financial representative is also available to answer your questions.
If you are unable to print a form or have any questions, contact your Thrivent Financial claim representative at mail@thrivent.com, attention Disability Income Insurance Claims, or call 800-THRIVENT (800-847-4836) and say "Health Insurance Claim" and then "Initiate a new claim". You will then be asked to provide your social security number. As always, your Thrivent Financial representative is also available to answer your questions.
Long Term Care Insurance
If you are unable to print a form or have any questions, contact your Thrivent Financial claim representative at mail@thrivent.com, attention Long Term Care Insurance Claims, or call 800-THRIVENT (800-847-4836) and say "Long Term Care Insurance". When asked if you are the Medicare Supplement provider, say "No". You will then be asked to provide your social security number. As always, your Thrivent Financial representative is also available to answer your questions.
If you are unable to print a form or have any questions, contact your Thrivent Financial claim representative at mail@thrivent.com, attention Long Term Care Insurance Claims, or call 800-THRIVENT (800-847-4836) and say "Long Term Care Insurance". When asked if you are the Medicare Supplement provider, say "No". You will then be asked to provide your social security number. As always, your Thrivent Financial representative is also available to answer your questions.
Medicare Supplement Insurance
Frequently Asked Questions
No claim forms are required. If you have any questions, contact your Thrivent Financial claim representative at mail@thrivent.com, attention Medicare Supplement Insurance, or call 800-THRIVENT (800-847-4836) and say "Health Insurance Claim" and then "Initiate a new claim". You will then be asked to provide your social security number. As always, your Thrivent Financial representative is also available to answer your questions.
Frequently Asked Questions
No claim forms are required. If you have any questions, contact your Thrivent Financial claim representative at mail@thrivent.com, attention Medicare Supplement Insurance, or call 800-THRIVENT (800-847-4836) and say "Health Insurance Claim" and then "Initiate a new claim". You will then be asked to provide your social security number. As always, your Thrivent Financial representative is also available to answer your questions.
Life Insurance Premium Waiver Benefit
If you are unable to print a form or have any questions, contact your Thrivent Financial claim representative at mail@thrivent.com, attention Life Insurance Premium Waiver Claims, or call 800-THRIVENT (800-847-4836) and say "Premium Waiver Claim". You will then be asked to provide your social security number. As always, your Thrivent Financial representative is also available to answer your questions.
If you are unable to print a form or have any questions, contact your Thrivent Financial claim representative at mail@thrivent.com, attention Life Insurance Premium Waiver Claims, or call 800-THRIVENT (800-847-4836) and say "Premium Waiver Claim". You will then be asked to provide your social security number. As always, your Thrivent Financial representative is also available to answer your questions.
Hospital Confinement
No special forms or claim forms are required. If you have any questions, contact your Thrivent Financial claim representative at mail@thrivent.com, attention Hospital Confinement, or call 800-THRIVENT (800-847-4836)and say "Health Insurance Claim". When prompted, say "Initiate a new claim". You will then be asked to provide your social security number As always, your Thrivent Financial representative is also available to answer your questions.
No special forms or claim forms are required. If you have any questions, contact your Thrivent Financial claim representative at mail@thrivent.com, attention Hospital Confinement, or call 800-THRIVENT (800-847-4836)and say "Health Insurance Claim". When prompted, say "Initiate a new claim". You will then be asked to provide your social security number As always, your Thrivent Financial representative is also available to answer your questions.
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