Check company which issued policy:
Transamerica Life Insurance Company
Transamerica Occidental Life Insurance Company
Monumental Life Insurance Company
Life Investors Insurance Company of America
Social Security No.
Policy Owner Name
(Last, First, M.I.)
Is this a new address?
Policy Owner home address
If Married, Spouse** of Policy Owner must signed if residence is in one of the community property states of: Arizona, California, Idaho, Louisiana, Nevada,
New Mexico, Texas, Washington, or Wisconsin.
In consideration of and exchange for the
of the above stated policy.
I/We hereby surrender said Contract for cancellation. (The policy should be returned with this form.)
In accordance with the terms of the Contract, it is hereby agreed that any indebtedness thereon to the Company will be deducted from the
Said (Cash)(Maturity) Value is accepted in full settlement and complete satisfaction of all rights, claims and demands under said Contract.
It is expressly represented and warranted that no other person, firm or corporation has any interest in said Contract except the undersigned and that no
proceedings in insolvency or bankruptcy have been instituted or are pending against the undersigned.
LOST POLICY STATEMENT
The original of the policy has been lost or destroyed, and to the best of my knowledge is not in the possession of any other person or firm. If the original
policy is located, I promise to return it to the Administrative Office of the Company.
Signed in (City/State)
Day of (Month/Year)
*Current Policy Owner Listed:
Spouse** (required in
community property states.)
Assignee (if applicable)
The cash or maturity value is payable at the Administrative Office of the Company and only in exchange for the Contract and the satisfactorily completed
THE REQUEST MUST BE DATED the day it is signed and all signatures must be written in full exactly as they appear in the Contract and must be in ink.
In the case of a woman who has been married since the contract was issued, her signature should be completed by adding her present name to the name
as it appears in the contract. All signatures must be separately witnessed.
Return Completed Forms to:
Transamerica Worksite Marketing
P.O. Box 8063
Little Rock, Arkansas 72203-8063
**Spouse or equivalent, as defined by governing state law.