Form L-52490 - Customer Service Request - Supplemental Benefits Page 2
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1
2You may surrender your policy for the cash surrender value, if any, otherwise
6.
Surrender/Cancellation of Policy
your policy will be cancelled. By electing this option, you surrender the policy
and all claims thereunder. If your policy has cash value, a check will be forwarded for the proceeds after deduction of
indebtedness and/or applicable surrender charges, if any.
Check box to confirm that no bankruptcy proceedings are now pending.
7.
Request for Duplicate Policy or Summary This policy was lost or destroyed. $25.00 Charge for duplicate policies.
Full given name, address, relationship and percentage must be given to be processed.
8.
Beneficiary Change(s)
If you are naming a minor child, you MUST include their date of birth. When naming a trust,
you MUST include the name and date of trust. Unless otherwise specified, proceeds are to be paid in equal shares to
the surviving beneficiaries, if more than one.
Relationship
Percent
To Insured
Primary
%
Name
No./Street
City
State
Zip
%
Name
No./Street
City
State
Zip
Relationship
Percent
To Insured
Contingent
%
Name
No./Street
City
State
Zip
%
Name
No./Street
City
State
Zip
9.
Coverage Changes
FROM (OLD POLICY)
TO (NEW POLICY)
Plan________________________________________
Plan________________________________________
Premium $___________________________________
Premium $___________________________________
Amount $____________________________________
Amount $____________________________________
Benefits_____________________________________
Benefits_____________________________________
Riders______________________________________
Riders______________________________________
Effective Date
Non Forfeiture Option:
Non Forfeiture Option:
APL
Reduced Paid Up
APL
Reduced Paid Up
The undersigned (No. 12) assignee releases all rights, title, and interest in this
10.
Policy Assignment Release
policy
11.
Additional Changes
Provident is hereby authorized to amend this request to correct obvious errors or omissions. If you live
12.
Signatures
in a community property state*, your spouse or ex-spouse MUST also sign this form. An adult other
than a relative or beneficiary MUST witness your signature.
Owner Soc. Sec. No.
Witness Signature
Date
Owner Signature
Spouse Signature
Spouse Soc. Sec. No.
Witness Signature
Date
Assignee Signature
Assignee Soc. Sec. No.
Witness Signature
Date
(
)
*Community Property States: AZ, CA, ID, LA, NV, NM, TX, WA, WI
THIS SECTION FOR PROVIDENT HOME OFFICE USE ONLY
Acknowledged
BY______________________________________________________________________ DATE_____________________
L-52490 (7/05)
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Parent category: Business