Request For Service Form - Colonial Life printable pdf download

Colonial Life

| REQUEST FOR SERVICE — LIFE | FAX: 1-877-828-9430 | Telephone: 1-800-325-4368

Request for Service Form

LIFE INSURANCE POLICIES ONLY

FAX this form: 1-877-828-9430

From:

Or mail: P.O. Box 1365, Columbia, SC 29202

FAX this direction

Number of pages:

Insured’s name:

Middle initial:

Last:

First:

Social Security number:

DOB: ______ / ______ /_____________

Mailing address:

City:

State:

ZIP:

Telephone:

Email:

Policy number(s)

–

Section 1

Choose only ONE option

Cancellation

I understand that by electing this option, I am forfeiting all claims to this policy.

If this policy has cash value, a check will be forwarded for the proceeds after

£ Policy

deduction of applicable surrender charges and outstanding loan balances, if any.

£ Spouse rider

£ Dependent rider

(cancels coverage for ALL dependents)

£ Other rider: ______________________________

Cancellation transactions terminate your coverage including any riders. If cancellation is selected on a policy with cash value, this is considered a

full cash surrender, and the policy cannot be reinstated.

> OR <

£ Policy loan

I am aware of the negative impact this loan could have on my policy. If the

specified amount is more than the available cash value, Colonial Life will process

I am requesting a loan against my Policy Cash Value:

this request for the maximum amount available.

£ Maximum amount available

£ I am also requesting information regarding repayment of my loan

£ Specific amount $____________________

on my Universal Life policy.

If a specified amount is not indicated, a maximum loan will be issued. Although policy loans are permitted under your contract, you need to be aware

of how this transaction will affect your policy. Interest will accrue daily on the outstanding policy loan and is due each year on the outstanding loan

balance. If the sum of the loan balance plus unpaid loan interest ever exceeds the cash value, the policy could terminate. In addition, the policy’s death

benefit will be reduced by the amount of any outstanding loan and unpaid loan interest due at the time of death or should you surrender the policy.

Please review the policy contract for more information.

> OR <

£ Withdrawal/partial surrender

I am aware of the negative impact this withdrawal/partial surrender will have

on my policy. If the specified amount is more than the available cash value,

I am requesting a withdrawal/partial surrender:

Colonial Life will process this request for the maximum amount available.

£ Maximum amount available

£ Specific amount $____________________

Universal Life policies only.

If a specified amount is not indicated, a maximum withdrawal will be issued. Although policy withdrawals are permitted

under your contract, you need to be aware of how this transaction will affect your policy. A policy withdrawal represents funds subtracted from the cash

value of the policy, lowers the death benefit of the policy and cannot be repaid. Because of this, the premium may need to be increased at some point in

the future or the policy could terminate.

Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. |

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