Request For Service Form printable pdf download

REQUEST FOR SERVICE FORM

LIFE INSURANCE POLICIES ONLY

(Please print all information clearly)

Named Insured __________________________________________________

Social Security Number _______________________

LAST

FIRST

Street Address _____________________________________

City _____________________

State __________

Zip ___________

Phone # (h) _____________________________

(w) _____________________________

DOB _____________________________

MM/DD/YYYY

Check here if the above address is a new address.

ONLY SELECT 1 OF THE 3 OPTIONS BELOW, PER POLICY NUMBER.

1. Policy Loan

Policy loans are available on Whole and Universal Life policies only. Loan transactions will affect the surrender value of your life

insurance policy. Although policy loans are permitted under your contract, you need to be aware of how this transaction will affect

your policy. Interest will accrue on your outstanding policy loan and is due on your outstanding loan balance. Unpaid loan interest

may cause your policy to terminate if the sum of your loan balance plus unpaid loan interest ever exceeds your cash value. In

addition, your policy proceeds payable will be reduced by the amount of any outstanding loan and unpaid loan interest due at the time

of death or should you surrender your policy.

Policy Number(s) ____________________________________________________________________________________________

I am requesting a policy loan for the maximum amount available

I am requesting a policy loan for the following amount $ _____________________________. If the amount requested

is more than the available cash value, we will process this request for the maximum amount available.

By setting up a systematic payment schedule to repay your loan, you can restore the cash value of your policy. You will receive

annual loan interest notices until the loan is paid in full. Whenever you are repaying your loan, please note on the check that it is a

loan payment.

I am also requesting information regarding repayment of my loan on my Universal Life policy

By signing on the reverse side, I hereby assign the policy to the insurer as collateral.

2. Withdrawal / Partial Surrender

For Universal Life policies only. Although policy withdrawals are permitted under your contract, you need to be aware of how this

transaction will affect your policy. Withdrawal transactions will affect the cash value of your life insurance policy. A policy withdrawal

represents funds subtracted from the cash value of your policy, lowers the death benefit of the policy and cannot be repaid.

Policy Number(s) ____________________________________________________________________________________________

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

I am requesting a policy withdrawal / partial surrender for the following amount $ _____________________________.

If the amount requested is more than the available cash value, we will process this request for the maximum amount

available.

3. Policy Cancellation, Surrender or Rider Cancellation

Surrender transactions terminate your coverage, including any riders. If there was a taxable gain on your policy cash surrender

value, we have withheld the applicable Federal Income Tax (FIT) unless you specified otherwise. If we withheld FIT, your proceeds

were reduced by the amount of the taxes withheld. Gains realized on any life insurance policies, when surrendered, are reported to

the Internal Revenue Service on Form 1099-R. We will mail you a 1099-R if gains are reported.

Policy Number(s) ____________________________________________________________________________________________

Cancel / surrender the policy(s). This option will cancel or cash surrender your policy.

Cancel the following riders on the policy(s). This option will cancel policy riders only.

Spouse rider

Dependent rider (This will cancel coverage for all dependents.)

Other (name rider) ________________________________________________

Request For Service Form

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