MassMutual Ascend Life Insurance Company

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Agent Information

Name

*

First		Middle		Last

Broker

Agency

Address

City

State

Zip Code

Phone

E-Mail

Agent Number

Select "Eligible" if the Designated Beneficiary is:

	•		A living person who is older than the Decedent; or
	•		A living person who is not more than 10 years younger than the Decedent; or
	•		A living person who is totally and permanently disabled or chronically ill on the Decedent’s date of death.

The above are eligible for Single Life Expectancy RMD payments.

Otherwise, select "Not Eligible."

Important

The premium amount requested will require
Home Office approval before being accepted.