Service Request Form Page 2
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1
2- Instructions and Conditions -
1.
CONTRACT
Complete all contract information in this section. You may use this form for multiple contracts that have the
IDENTIFICATION
same contract owner and require the same signatures.
This form may be used to change your direct billing frequency. For all other premium changes, including
2.
CHANGE DIRECT
changes to your billing method and electronic funds authorization, please contact your Service Center. Check
BILLING
the box to indicate the billing frequency. For flexible premium products, please fill in the planned premium.
FREQUENCY
Check the box identifying the reason for a Contract Certificate. This one page Certificate provides basic contract
3.
LOST CONTRACT
information and will serve as proof of your coverage.
CERTIFICATE
Check the box of the person whose age needs to be corrected. If it is a child, provide the name of the child.
4.
CORRECT AGE
Provide correct date of birth. Proof of age, such as a birth certificate or driver’s license, must be provided.
Please submit a copy rather than the original document.
Check the box to indicate which option you choose to select. Review your contract to determine which
5.
CHANGE
provisions are allowed and how the provisions affect your contract.
NONFORFEITURE
OPTION
Extended Term Insurance (ETI) utilizes the cash surrender value to purchase term insurance until that value
is depleted. Upon expiration, the contract terminates without value. Any outstanding loan balance will be
paid off.
Reduced Paid Up Insurance (RPU) utilizes the cash surrender value to provide a paid up contract for a
reduced amount of coverage. Depending on the contract, you may have the option to leave any outstanding
loan on the policy.
Automatic Premium Loan (APL) allows for a contract loan to pay a premium due provided that there is
sufficient cash value.
Check the box to indicate which option you choose to select. Review your contract to determine which
6.
EXECUTE
provisions are allowed and how the provisions affect your contract as benefits and riders may be terminated.
NONFORFEITURE
OPTION
Extended Term Insurance (ETI) utilizes the cash surrender value to purchase term insurance until that value
is depleted. Upon expiration, the contract terminates without value. Any outstanding loan balance will be
paid off.
Reduced Paid Up Insurance (RPU) utilizes the cash surrender value to provide a paid up contract for a
reduced amount of coverage. Depending on the contract, you may have the option to leave the loan on the
policy.
Automatic Premium Loan (APL) allows for a contract loan to pay a premium due provided that there is
sufficient cash value.
7.
CHANGE
If your contract earns dividends, select one option. Review your contract to determine which dividend
DIVIDEND
options apply.
OPTION
Check the box to indicate which benefit or rider you want to remove. You may be contacted by the Service
8.
CANCEL BENEFITS
OR RIDERS
Center if your state requires additional forms to complete processing.
This request must be dated and all required signatures must be written in ink, using full legal names.
9.
SIGN HERE FOR
ABOVE REQUEST
Taxpayer Identification Number Certification: You must cross out item 2 if you have been notified by the IRS
that you are currently subject to backup withholding because you have failed to report all interest or
dividends on your tax return.
This request must be signed by
• the person or persons who have the rights of ownership under the terms of the contract (co-owners,
irrevocable beneficiary);
• by any other party who may have an interest in the contract by legal proceedings or statutes; and
• the spouse of the owner must also sign this request, if the owner resides in a Community Property state.
(Community Property states are AZ, CA, ID, LA, NM, NV, TX, WA and WI).
Special circumstances – Corporate ownership: The signature of one officer followed by the officer’s title is
required. The request must be submitted on a piece of corporate letterhead or paper with the corporate seal
signed by that officer; Partnerships: The full name of the partnership should be written followed by the
signatures of all partner(s), other than the Insured; Trust: If the contract is owned by or assigned to a Trustee,
current Trustee(s) signatures are required as instructed by the trust agreement. Validation of Trustee(s)
signatures may be required.
AGLC0107
Page 2 of 2
Rev0904
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