Certificate Of Cancellation And Application For Withdrawal Insurance-Funded Prepaid Funeral Contract Form
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1CERTIFICATE OF CANCELLATION AND APPLICATION FOR WITHDRAWAL
INSURANCE-FUNDED PREPAID FUNERAL CONTRACT
To (Depository): _____________________________________________________________________________________________
From (Seller) Name:
____________________________________________________
Permit Number: __________________
Address:_____________________________________________________
City, State, Zip:_______________________________________________
Telephone/Fax Numbers: _______________________________________
Prepaid Contract No. ______________ Insurance Policy/Certificate No. _______________ Cash Value $_____________________
We, the undersigned parties entered into a prepaid funeral contract dated ___________. The sum above is the current cash value of the
policy coverage that funds the purchaser’s prepaid funeral contract. We have agreed to cancel such contract. Therefore, we authorize the
depository, recipient of premiums for the insurance coverage funding the purchaser’s prepaid funeral contract, to pay the cash value to the
purchaser in accordance with the contract cancellation clause and the terms of the insurance policy/certificate shown above.
PURCHASER
My signature on this application for withdrawal indicates my desire to receive a cash refund of the cash value of the policy/certificate
of insurance (unless otherwise noted below) and cancel the prepaid funeral contract. Neither the funeral director nor any seller of
prepaid funeral benefits contracts suggested that I cancel this contract.
NOTE: The cancellation of your existing contract to buy another may well be to your disadvantage. It is easy to misunderstand the
facts when converting from one contract to another. Read any new contracts carefully.
•
If you have any complaints concerning the cancellation of your prepaid funeral contract, you may contact the Texas Department
of Banking, Special Audits Division, toll-free at (877) 276-5554.
•
If you are being asked to convert your present prepaid funeral contract to another prepaid funeral contract or if the Seller is
soliciting this cancellation, please DO NOT SIGN THIS FORM before contacting the Department of Banking.
•
If you are not the original purchaser of the funeral contract, you must provide legal documentation to the Seller that you have the
authority to request this cancellation.
If you are canceling this contract and applying your refund to another contract and insurance policy from this same seller, you
MUST initial this paragraph as indication that you acknowledge your refund will be applied directly to your new contract and
insurance policy and no refund check will be issued. (Initial here: _____________)
__________________________________________________________
___________________________________________
Signature of Purchaser
Date
__________________________________________________________
___________________________________________
Street Address
City, State, Zip
STATE OF ____________________________
COUNTY OF __________________________
________________________________________________, the purchaser, personally appeared before me and being first duly sworn,
declared he/she signed this application in the capacity designated and stated he/she has read the application and that the statements in
the application are true and correct.
Sworn to and subscribed before me this _________ day of _________________________, 20______.
____________________________________________________
___________________________________________
Signature of Notary Public
Date Commission Expires
SELLER
_________________________________________________________
(Seller) certifies that the amount shown on this
application for withdrawal represents the total amount available under the terms of the insurance policy/certificate. To my knowledge,
neither I nor any of my agents encouraged or solicited the customer to cancel this contract.
_____________________________________________________
___________________________________________
Signature of Seller’s Approved Designated Agent
Date
____________________________________________________________________________________________________________
Printed Name and Title of Seller’s Approved Designated Agent
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