Form: Authorization to Disclose

Method 1: Submit Electronically

Fill out the form on the lower half of this page – Click here

OR

Method 2: Print and Mail

Click here to download a PDF of the Authorization to Disclose form.

Screen Shot 2015-05-19 at 11.24.28 AMSend completed form to:

Polish Roman Catholic Union of America
Attn: Annuity Department
984 N. Milwaukee Ave.
Chicago, IL 60642-4101

If you have any questions please contact us online or call 1-800-772-8632

1. Account Information (Leave Blank for New Applications)






2. Annuitant Information - Required

*Required Field

Name*:

Address*:




State:

Phone Number*:
() - x

Work Phone Number:
() - x

E-Mail Address*:

Date of Birth*:
/ /

3. Secret Control Question - Required

To help PRCUA employees with validating your identity when you call us, we will ask you your selected secret control question and anticipate the answer you provide in the boxes following the selected secret control question. You may select one of the predefined questions or you may enter your own custom question in order to provide a higher level of security.
Please select only ONE secret control question.

What city were you born in?

When is your wedding anniversary? / /

What is your favorite sports team?

What is your favorite color?

I want to enter my own custom secret control question:


4. Authorized Third-Party Individuals - Optional

You can specify third-party individuals, such as a family member, spouse or personal financial advisor, who are authorized to receive information about your account and the transaction relating to your account.

Name 1:

Name 2:

Name 3:

Name 4:

You can also authorize your current PRCUA sales representative (deputy/agent). Allowing your current PRCUA sales representative (deputy/agent) with access to your account information and transaction history will provide them with information necessary to effectively provide you with future assistance.

PRCUA sales representatives are bound by the terms of the PRCUA Privacy Policy and are authorized to use your account information only for servicing your financial protection with the use of PRCUA offered financial products/services.

I authorize the PRCUA sales representative below to have access to my annuity account information:

5. Signature
I understand and agree with the Terms of Use as stated by the PRCUA and the completion of this form is accepted as my digital signature for processing and enrollment.

* Please verify you are a human:

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