Request For Service Form - Colonial Life (Page 2 of 2) in pdf

Colonial Life

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

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Section 2

Tax withholding options

(complete this section if you are requesting a cancellation 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.

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.

£ I DO want to have Federal Income Tax withheld.

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 proceeds in the event any policy benefits become payable.

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 and requirements. I certify that the policy is not pledged or assigned to

any other person or corporation, except where stated in 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 Life to execute this request.

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Section 3

Required signature

_______________________________________________________________________________

________________________________

Policy owner’s signature

Date (MM/DD/YYYY)

Name of policy owner:

SSN:

DOB: ______ /______ /__________