Policy Service Request
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1
2POLICY SERVICE REQUEST (Policy Required if Indicated)
KANAWHA INSURANCE COMPANY, P O Box 610, Lancaster, SC 29721-0610
INSURED’S NAME _______________________________________________________ POLICY NUMBER ________________________________________
OWNER’S NAME _________________________________________________________ OWNER’S SOCIAL SECURITY # __________________________
OWNER’S ADDRESS ________________________________________________________________________________________________________________
STREET ADDRESS
___________________________________ ¨ YES ¨ NO __________________________________________________________________________________
CITY
CITY LIMITS
STATE
COUNTY
ZIP+4
OWNER’S TELEPHONE ________________________________________________ COMPANY IDENTIFICATION # _______________________________
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Section A — PAYOR ADDRESS CHANGE
Section E — DIVIDEND OPTION CHANGE
____________________________________________________________
¨ Paid in Cash
¨ Left to Accumulate
____________________________________________________________
¨ Premium Reduction
(Direct Bill Only)
____________________________________________________________
(Complete Form 6106 Sec. A for Paid-up Additions)
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Section F — POLICY VALUE OPTIONS
_______________________________
¨ YES ¨ NO _________________________
I request that my policy be placed on:
County
City Limits
¨ Reduced Paid-Up Insurance
(Premium must be current)
¨ Extended Term Insurance
(Premium must be current)
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Section B — CHANGE NAME
(Does not change designation)
Discontinue Premium Payments Effective ______________
¨ Beneficiary _______________________________________________
(If a Vanishing Premium is requested, complete form # 6096)
____________________________________________________________
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Section G — PLAN CHANGE, REDUCTION
____________________________________________________________
AND/OR REMOVAL
(Policy Required)
Relationship ________________________ Date of Birth ____________
¨ Change plan of insurance:
¨ Insured __________________________________________________
From _____________________ To ______________________
¨ Contingent Beneficiary _____________________________________
¨ Reduce amount of ins. to:
____________________________________________________________
Effective ____________________________________________
¨ Applicant _________________________________________________
¨ Remove Dependent, Benefit or Rider
¨ Payor ____________________________________________________
____________________________________________________
¨ Owner ___________________________________________________
Effective ____________________________________________
(Due to marriage only)
Complete Form 6106 if changing plan from Tobacco User to
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Section C — PREMIUM CHANGES
Non-Tobacco User.
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Section H — DATE CHANGE
1. Change Premium Payment:
¨ Annual
¨ Semi-annual
¨ Quarterly
¨ Change Date of Policy to ___________________________
¨ Home Office Bill ¨ Bank Draft
¨ Change Date of Birth to ____________________________
(Bank Authority & voided check req’d)
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¨ Payroll Deduction
Section I — IRA ELECTION
(Requires Payroll Authority & current premium)
Contact Home Office for Special Request and Minimum Requirements.
¨ Direct that $ __________________________ contribution
be irrevocably applied to tax year 19 _____________
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Section D — CONVERT INSURANCE TO:
(Policy Required)
¨ Change Annual Annuity Targeted Contribution
Plan _________________ Premium _____________________________
Amount to $ _____________________________________
Divident Election:
SEE SECTION E
Effective ________________________________________
Ins. Amount: _________ Effective _____________________________
¨ Discontinue Annuity Contribution Effection
Tobacco User: _______ Non-Tobacco User: ___________________
Have you used tobacco products in the last 12 months? ¨ YES ¨ NO
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Section J —
¨ Duplicate policy ($25.00 Fee)
A urine specimen is requried if original was not a NTU Plan.
¨ Policy Certificate (no charge)
¨ Continue Remaining Insurance, or
¨ Cancel Remaining Insurance
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Section K — SPECIAL REQUEST
¨ Continue
¨ Terminate
¨ Continue
__________________________________________
¨ Children’s Rider
¨ Children’s Rider
¨ WP
__________________________________________
¨ AD&D Rider
¨ AD&D Rider
If the Policy requires that the above change(s) be endorsed in the Policy, it is requested that the Policy be modified to permit the change(s) without
endorsement of the Policy.
Witness _________________________________________________________
_____________________________________
______________________
AGENT
POLICYOWNER
DATE
Witness _______________________________________________________________ My Commission Expires _______________________________________
NOTARY PUBLIC
6016B 01/03
72-99
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