Policy Service Request (Page 2 of 2) in pdf

POLICY 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 ADRESS _________________________________________________________________________________________________________________

STREET ADDRESS

_____________________________________ ¨ YES ¨ NO _______________________________________________________________________________

CITY

CITY LIMITS

STATE

COUNTY

ZIP+4

OWNER’S TELEPHONE (

)

COMPANY IDENTIFICATION # _______________________________

Section A — SURRENDER OF POLICY FOR CASH VALUE

Section B — WITHDRAWAL OF DIVIDENDS

LESS ANY INDEBTEDNESS: (Policy Required)

¨ Cash Surrender of Paid-up Additions/Accumulations

Check one box:

¨ $___________of Paid-up Additions/Accumulations

¨ Policy attached or

¨ Policy is lost and cannot be found

Section C — POLICY LOAN

¨ $ ______________________ Specify Amount

¨ Maximum Loan

If a premium for this policy is to be deducted, specify amount $ ____________________ and due date _________________________________ .

(Interest is payable annually in advance of the Policy Anniversary date, at the rate stated in the policy. If the interest is not paid, it is added

to the loan. The Policy Loan is a first lien on the policy.)

Section D — WITHDRAWAL OF ANNUITY FUNDS

¨ $ ______________________ Specify Amount: Minimum $250/Maximum 90% of Cash Value

¨ Surrender for Total Cash Value (Policy Required)

Check one box:

¨ Policy attached or

¨ Policy is lost and cannot be found.

Rollover ¨ Yes ¨ No

UNDER THE TAX EQUITY AND FEDERAL RESPONSIBILITY ACT OF 1982, WE ARE REQUIRED TO REPORT DEPOSITS AND

WITHDRAWALS. KANAWHA MUST WITHHOLD 10% FEDERAL INCOME TAX ON WITHDRAWALS AND SURRENDERS. EVEN IF

YOU SPECIFICALLY ELECT NOT TO HAVE FEDERAL INCOME TAX WITHHELD, YOU ARE LIABLE FOR PAYMENT OF FEDERAL

INCOME TAX ON THE TAXABLE PORTION OF YOUR SURRENDER OR WITHDRAWAL. YOU MAY ALSO BE SUBJECT TO TAX

PENALTIES UNDER THE ESTIMATED TAX PAYMENT RULES IF YOUR PAYMENTS OF ESTIMATED TAX & WITHHOLDING, IF ANY,

ARE NOT ADEQUATE.

¨ I do not want federal income tax withheld.

¨ I want federal income tax withheld.

WITH RESPECT TO ANY FUNDS RECEIVED FOR LOAN, SURRENDER, WITHDRAWAL OF DIVIDENDS OR ANNUITY FUNDS, THE

UNDERSIGNED HEREBY WARRANTS THAT NO ONE OTHER THAN THE UNDERSIGNED HAS ANY INTEREST IN OR CLAIM ON SAID

POLICY AND THAT NO PROCEEDING IN BANKRUPTCY HAS BEEN INSTITUTED BY OR AGAINST THESE FUNDS.

IF ANY OF THE ABOVE REQUESTS TERMINATE THIS POLICY AND THE MARRIED NAME OF A FEMALE POLICYOWNER HAS NOT BEEN

ENDORSED ON THE COMPANY RECORDS, THE SIGNING OF THE OWNER’S MAIDEN NAME IN FULL WITH THE MARRIED NAME ADDED

IS REQUEST TO MAKE THE CHANGE ON COMPANY RECORDS AND TO MAKE PROCEEDS PAYABLE TO THE OWNER IN HER MARRIED

NAME.

Witness _______________________________________________________________

_____________________________________

_________________

AGENT

POLICYOWNER

DATE

Witness ____________________________________________________________________ My Commission Expires __________________________________

NOTARY PUBLIC

______________________________________________

___________________________

SERVICING AGENT

DATE

FOR HOME OFFICE USE ONLY

Date Transaction Completed __________________________ Check Number _________________________ Register Clear _________________________

By __________________________________________________

6016A 01/03

72-99

Policy Service Request Page 2

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