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

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 realized 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 resulting in taxable income for the current

tax year. If a gain is reportable, an IRS Form 1099-R will be sent to you at the beginning of the next calendar year, reporting the realized

gain, and a copy of Form 1099-R will be sent to the IRS. If a gain is reportable, the insurer is required to withhold 10% federal tax from the

payment unless the policy owner elects not to have any federal tax withheld.

Choose one of the following options for Federal tax withholding: (If an option is not selected, we will automatically withhold for the tax.)

I DO NOT want Federal Income Tax withheld.

I DO want Federal Income Tax withheld.

Special Notice for Residents of a Community Property State: A spouse of 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 proceeds in the event any policy benefits become payable.

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 social security number and date of birth may delay processing.

Policy owner’s Social Security Number _______________________

Policy owner’s Date of Birth ____________________

MM/DD/YYYY

Policy owner’s mailing address _____________________________________________________________________________________

STREET

CITY

STATE

ZIP

Policy owner’s daytime phone # ______________________________________ Policy owner’s Email ____________________________

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 further certify that the policy(s) is not jointly owned community property or in the alternative,

applicable consents have been received.

I certify the Social Security Number and Date of Birth indicated is correct, and I hereby authorize Colonial

to execute this request.

Policy owner’s name (printed) ______________________________________________________________________________________

Policy owner’s signature _________________________________________________________

Date ___________________________

** Policyowner may be different than the premium payor or insured person**

**Only complete this section if there is an assignment on your life policy(s)**

Assignee’s name (printed, if any) ___________________________________________________________________________________

Assignee’s signature (if any) ______________________________________________________

Date ___________________________

PLEASE BE SURE TO SIGN AND DATE

MAIL TO:

FAX TO:

Colonial Life Insurance Processing Center

PO Box 100130, Columbia, SC 29202-3130

1.877.828.9430

6/12

73712-4

Request For Service Form Page 2

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