Policy Service Request Form
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1
2Policy Service Request
(Policy Required if indicated)
Kanawha Insurance Company, P.O. Box 7200, Lancaster, SC 29721
Insured’s Name ____________________________________________ Policy Number ____________________________________
Owner’s Name ____________________________________________ Owner’s Social Security Number _____________________
Owner’s Address ____________________________________________________________________________________________
City ______________________________________________ State _____________________________ ZIP+4 ________________
Owner’s Telephone __________________________________________________________________________________________
Section A — Payor Address Change
Address _________________________________________________________________________________________________
City ____________________________________________ State _____________________________ ZIP+4 ________________
Section B — Legal Change Name (Does not change designation)
Beneficiary _____________________________________________________________________________________________
Relationship __________________________________________ Date of Birth ___________/_____________/_____________
Insured ________________________________________________________________________________________________
Contingent Beneficiary ___________________________________________________________________________________
Applicant _____________________________________________ Payor ____________________________________________
Owner ________________________________________________________________________________________________
Section C — Premium Changes (Requires Home Office approval)
Change Premium Payment:
Annual
Semi-annual
Direct Bill
Credit Card
(Credit Card Authorization required)
Quarterly
Monthly
Bank Draft
(Bank Authorization & voided check required)
Contact Home Office for Special Request and Minimum Requirements.
Section D — Convert Insurance To:
Product/Plan ____________________________________________ Modal Premium ___________________________________
Insurance Amount _______________________________________ Effective _____________/______________/_____________
Tobacco User:
Yes
No
Have you used tobacco products in the last 12 months?
Yes
No
A urine specimen is required if original was not a NTU Plan.
Continue Remaining Insurance, or
Cancel Remaining Insurance
Continue
Terminate
Children’s Rider
Waiver of Premium
AD&D Rider
Dividend Option: (Complete Form 6106 Section A for Paid-up Additions)
Paid in Cash
Left to Accumulate
Premium Reduction (Direct Bill Only)
Section E — Policy Value Options (Premium must be current)
I request that my policy be placed on:
Reduced Paid-Up Insurance
Extended Term Insurance
Discontinue Premium Payments Effective _____________________/___________________________/_____________________
(If requesting premium reduction via dividend, complete Form 6096)
Section F — Plan Change, Reduction and/or Removal
Coverage Change Effective _______________________________/____________________________/______________________
Change product/plan of insurance: From _________________________ To ________________________________________
Reduce amount of insurance to: ___________________________________________________________________________
Remove Dependent, Benefit or Rider ________________________________________________________________________
(Complete Form 6106 if changing plan from Tobacco User to Non-Tobacco User.)
Change Date of Birth to _______/_________/_________ Name of Insured that Change Applies to _____________________
Section G
Policy Certificate
Duplicate policy
Section H — Cancel Policy
I confirm that I wish to cancel the above listed policies.
Effective date of cancellation will be determined as defined by our Procedural Cancellation Policy.
If the Policy requires that the above change(s) be endorsed in the Policy, it is requested that the Policy be modified to permit
the change(s) without endorsement of the Policy.
Signature _____________________________________________ _________________/__________________/________________
Policyowner
Date
6016B 4/10
GCA09JMHH
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Parent category: Business