Policy Surrender/full Withdrawal Application Form printable pdf download

*PPH1PSFWAF*

Policy Number(s)

Policy Surrender/Full Withdrawal

Application Form

Important Notes:

1. This form is to be accomplished by the Policy Owner/Assignee in BLOCK LETTERS.

FOR OFFICE USE ONLY

2. Please do not sign on a blank form.

Date Received: ____________

3. Please put a shade in the circle to indicate your choice(s).

Time Received: ____________

Type of Transaction

Receiving

Dept./Office: ______________

Policy Surrender (Traditional Life Policy)

Full Withdrawal (Variable Life Policy)

FOR DISTRIBUTOR’S USE ONLY

Policy Details

FE/Advisor’s code:

__________________________

Full Name of Insured (Last Name, First Name, Middle Initial)

FE/Advisor’s name:

__________________________

Phone No.

Cellphone No.

FE/Advisor’s mobile number:

Full Name of Policy Owner (Last Name, First Name, Middle Initial)

__________________________

Phone No.

Cellphone No.

Full Name of Assignee

Requirements:

Photocopy of primary valid ID

Phone No.

Cellphone No.

Pls. be ready to present original

ID when required

Policy Contract or Declaration

of Lost Policy in case of lost

contract

What you shoud know about early surrender of your policy

Note:

An insurance policy is intended to meet your long term financial needs and it is in your best interest to keep it in-

force. When you surrender a policy, you not only lose its valuable benefits but also discount the opportunity of

For your own protection and

acquiring it favorably.

benefits, we are always glad to

help review your insurance policy

with you. Please contact our

In the event that you were suggested to surrender this policy and start another one, the ensuing disadvantages of

Customer Service Hotline at

said action include higher premium rates due to older age or change in health conditions, loss of some or all of

581-5292, 323-1292

potential savings, exposure to policy exclusions such as “Incontestability”, “Pre-Existing Conditions”, and the like.

Keeping your best interest at heart, we will be glad to analyze and assess the relative merits of your policy and the

suggested replacement at no cost to you.

Reason for Surrender/or Withdrawal

Will proceeds for this request be used to fund a new AXA policy?

Yes

Pls. apply the proceeds to my new policy

FOR OFFICE USE:

If yes, please check customer record &

Reason: ___________________________

indicate policy number ___________________________

__________________________________

of 5

PPH1PSFWAF2011.07

Policy Surrender/full Withdrawal Application Form

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