Form 05897-30 - Request For Service - Colonial Life & Accident Insurance Company (Page 2 of 2) in pdf

WIthdraWal/PartIal surrender

(Universal Life Policy) Complete sections 9 & 12. Select either Policy Loan Section 7 or Withdrawal.

 I am requesting a policy withdrawal/partial surrender for the following amount: $___________

If the amount requested is more than the

Please selection

available cash value, we will process this

one option.

 I am requesting a policy withdrawal /partial surrender for the maximum amount available.

request for the maximum amount available.

Only one policy withdrawal/partial surrender is allowed per policy year. Minimum withdrawal amounts apply as stated in your policy contract. There will be a

processing fee as stated in your policy contract. Policy withdrawals/partial surrenders are available on universal life policies only. If your policy is not a universal life

policy and you request a withdrawal, we will process the request as a policy loan.

tax WIthholdInG oPtIons

( Please read and complete this section if you are requesting a surrender or withdrawal. )

Election of a tax withholding option is not available for tax-qualified products. The insurer is required to withhold 20% of any recognized gain for tax-qualified

products unless proceeds are rolled directly into an IRA or other qualified retirement plan.

Under certain criteria established by the Treasury Department, a gain may be reportable by the insurer at the time of surrender, partial surrender or withdrawal of

this policy, creating a taxable situation. However, any gain is taxable income for the current tax year.

If a gain is reportable, an IRS Form 1099R will be sent to you at the beginning of the next calendar year, reporting the recognized gain, and a copy of Form 1099R

will be sent to the IRS. If a gain is not reportable when the surrender, partial surrender or withdrawal is processed, an IRS Form 1099R will not be sent. In addition, if

a gain is reportable, the insurer is required to withhold 10% of any recognized gain, unless the policy owner elects not to have the tax withheld. You may be subject

to penalties under the estimated tax payment rules if you elect not to have tax withheld and payments of estimated tax and other withholding are not adequate to

satisfy tax liability.

Choose one of the following options. If an option is not selected, a withholding will automatically be made.

 I do not want to have Federal Income Tax withheld in conjunction with this surrender/partial surrender/withdrawal.

 I do want to have Federal Income Tax withheld from the surrender/partial surrender/withdrawal proceeds.

sPeCIal notICe for resIdents of a CommunIty ProPerty state

A spouse or former spouse may have an interest in life insurance proceeds or any accumulated cash value if the policy premiums were paid with community funds.

It is your responsibility to consult your legal advisor to 1) ensure that any required consent from a spouse or former spouse has been received and 2) ensure that

your spouse or former spouse will not be able to make a claim against any policy values and/or the proceeds in the event any policy benefits become payable.

other requests or remarks

(Includes illustration changes, face decrease, age discrepencies, or premium increase, etc.)

______________________________________________________________________________________________________________

sIGnatures requIred

( You must fill out this section COMPLETELY in order for us to process your request. )

➡ BE SURE TO LIST A SOCIAL SECURITY NUMBER AND DATE OF BIRTH BELOW. FAILURE TO PROVIDE THIS INFORMATION MAY DELAY PROCESSING.

I have carefully read this request and agree that it is properly and fully completed. I understand that this request is subject to the provisions and conditions of

the policy and that the company may require additional information or requirements. I certify that the policy is not pledged or assigned to any other person or

corporation, except where stated in the request, and that no proceedings or bankruptcy or insolvency have been filed or are now pending.

I certify the Social Security Number and Date of Birth indicated is correct, and I hereby authorize Colonial Life to execute this request.

Print Policy Owner’s Name:___________________________________________________ Policy Owner’s Social Security Number:________________________

Policy owner’s address:______________________________________________________

and Policy Owner’s Date of Birth:________________________

______________________________________________________________________

Policy Owner’s Email Address: ____________________________________________________ Daytime Telephone:__________________________________

Policy owner’s signature:_____________________________________________________________________ date:

__________________

(MM/DD/YYYY)

Assignee’s signature (if any):_____________________________________________________________________ Date:

__________________

(MM/DD/YYYY)

maIl to: Colonial life & accident Insurance Company, P.o. Box 1365, Columbia, sC 29202-1365

Phone: 1.800.325.4368 / to fax requests: 1.800.561.3082

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05897-30

Form 05897-30 - Request For Service - Colonial Life & Accident Insurance Company Page 2

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