Form 05897-32 - Request For Service Form printable pdf download

Colonial Life | REQUEST FOR SERVICE | FAX: 1-800-561-3082 | Telephone: 1-800-325-4368

Request for Service Form

FAX this form: 1-800-561-3082

From:

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

FAX this direction

Number of pages:

Please check only the boxes that apply to the service you are requesting.

–

Section 1

General information

(please use blue or black ink to complete this form)

Insured’s name:

DOB: _____ /_____ /________ SSN:

(As currently listed on the policy/certificate)

Address:

City:

State:

ZIP:

Telephone:

Mobile:

Email:

List all policy/certificate numbers related to this request:

(Required to process)

Employer:

–

£ Section 2

Name change

Current:

Reason:

Marriage/Divorce

Correction*

Other*

*A copy of legal documentation is required unless your name is changing due to reason of marriage or divorce.

–

£ Section 3

Address change

Address:

City:

State:

ZIP:

Telephone:

Mobile:

Email:

–

Section 4

Premium payment method change

(select only ONE option)

1. Deduct premiums monthly from my bank account.

1st-5th

6th-10th

11th-15th

16th-20th

21st-26th

______________________________________________________

Your draft will occur on one of the dates within the range you have selected. Please include a voided check or

Signature of bank account owner

Routing #_________________________ and Account # _________________________________

2. Bill me directly. (

Choose one of the following)

Quarterly

Semi-annually

Annually

(Submit a payment 3 times your monthly premium)

(Submit a payment 6 times your monthly premium)

(Submit a payment 12 times your monthly premium)

3. Change to payroll deductions

(Please contact your Plan Administrator to start payroll deduction.)

Employer:______________________________________________________________

Billing control/account number:__________________________________

–

Section 5

Cancellation, Surrender or Policy/Certificate Change

(also complete section 8 for surrender’s only )

Cancel/surrender the policy(ies)/certificate(s)

(This option will cancel or cash surrender your policy(ies)/certificate(s).)

Spouse Rider

Dependent Rider (This will cancel coverage for ALL

Other (name rider)

Cancel the following riders on the

policy(ies)/certificate(s):

dependents.) List date of birth of youngest dependent:

________________________

(This option will cancel policy/certificate riders only.)

____________________________

(MM/DD/YYYY)

Change Two-Parent to Individual

Change Two-Parent to One-Parent

Change One-Parent to Individual

Spouse/Dependent Continuation

Provide name, date of birth (DOB) and Social Security number (SSN) for spouse/dependent(s) continuation. If more space is needed, please provide the information in Section 9.

Name:

DOB:

SSN:

Name:

DOB:

SSN:

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

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Form 05897-32 - Request For Service Form

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