Request For Surrender - Transamerica printable pdf download

Check company which issued policy:

Request for

Transamerica Life Insurance Company

Surrender

Transamerica Occidental Life Insurance Company

Monumental Life Insurance Company

Life Investors Insurance Company of America

Social Security No.

Policy No.

Insured Name

Policy Owner Name

(Last, First, M.I.)

Home address

Is this a new address?

Yes

City

State

Zip code

Marital Status

Married

Single

Policy Owner home address

City

State

Zip code

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.

Cash Value

In consideration of and exchange for the

of $

of the above stated policy.

Maturity Value

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

(Cash)(Maturity) Value.

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)

This

Day of (Month/Year)

Policy Owner

Witness

*Current Policy Owner Listed:

Spouse** (required in

community property states.)

Witness

Assignee (if applicable)

Witness

Instructions

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

release.

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

(888) 763-7474

TWM-Surrender-022208

**Spouse or equivalent, as defined by governing state law.