Policy Service Request Form (Page 2 of 2) in pdf

Policy Service Request

(Policy Required if indicated)

Kanawha Insurance Company, P.O. Box 610, Lancaster, SC 29721-0610

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 — Surrender of Policy for Cash Value Less any Indebtedness (Policy Required)

Check one box:

Policy attached or

Policy is lost and cannot be found

Section B — Withdrawal of Dividends

Cash Surrender of Paid-up Additions/Accumulations

$_______________________ of Paid-up Additions/Accumulations

Section C — Policy Loan

$_______________________ Specify Amount

Maximum Loan

If a premium for this policy is to be deducted, specify amount $ ____________ and due date ________/_________/_______.

(Interest is payable annually in advance of the Policy Anniversary date, at the rate stated in the policy. If the interest is not

paid, it is added to the loan.

The Policy Loan is a first lien on the policy.)

With respect to any funds received for loan, surrender, or withdrawal of dividends, the undersigned hereby

warrants that no one other than the undersigned has any interest in or claim on said policy and that no

proceeding in bankruptcy has been instituted.

Signature _____________________________________________ _________________/__________________/_______________

Policyowner

Date

FOR HOME OFFICE USE ONLY

Date Transaction Completed _____/______/______ Check Number __________________ Register Clear ___________________

By _______________________________________________________________________________________________________

6016A 4/10

GCA09JMHH

Policy Service Request Form Page 2