Form 140 Dividend Option Change Catholic Order Of Foresters

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B R I N G I N G C A T H O L I C V A L U E S T O L I F E
DIVIDEND OPTION CHANGE/
A CATHOLIC FRATERNAL BENEFIT LIFE INSURANCE SOCIETY SINCE 1883
WITHDRAWAL REQUEST FORM
355 Shuman Boulevard, PO Box 3012, Naperville, IL 60566-7012
Toll-free 800-552-0145 | TTY 800-617-4176 |
Use this form for a one-time withdrawal request or to change the dividend option on a life insurance policy. Unless Section 4 is completed
(signatures endorsed on page 3) this form will be rejected.
POLICY #
INSURED NAME (First, MI, Last)
DATE OF BIRTH
SECTION 1: OWNER/TRUST/BUSINESS ENTITY
OWNER/TRUST OR BUSINESS ENTITY NAME
DATE OF BIRTH (if applicable)
SOCIAL SECURITY # OR TAX ID #
DATE EXECUTED (if a Trust)
PRIMARY PHONE NUMBER
TRUSTEE NAMES IF A TRUST (Provide a hard copy of trust) OR BUSINESS AUTHORIZED OFFICER NAME AND TITLE
EMAIL ADDRESS
STREET ADDRESS
CITY
STATE
ZIP
Use the above address for all future correspondence?
☐ Yes ☐ No
(Yes changes the address of record)
SECTION 2: ONE-TIME WITHDRAWAL REQUEST
WITHDRAWAL TYPE
☐ Dividend Withdrawal
☐ Entire account
☐ Specified amount
$
1
☐ Rider Withdrawal
Rider Name
☐ Entire account
☐ Specified amount
$
1
☐ Internal Paid-Up Insurance (Genesis Life only)
☐ Entire account
☐ Specified amount
$
1
☐ IBA/Advance Pay Account (Note: By withdrawing these funds, you may be required to resume premium payments)
☐ Entire account
☐ Specified amount
$
1
HOW TO APPLY THE WITHDRAWAL REQUEST
Apply the withdrawal request from Section 2, above as follows:
☐ Issue check to Owner
Proceeds will be mailed to the address of record.
☐ Apply to PAY PREMIUM(S) Policy Number
Premium Amount $
Policy Number
Premium Amount $
☐ Apply to PAY LOAN(S)
Policy Number
Loan Amount $
Policy Number
Loan Amount $
If requested funds are for the Advance Payment of Premium, complete and return form GO-192. Funds will not be accepted unless form
GO-192 is received by the Home Office. Unless Section 4 is completed (signatures endorsed on page 3) this form will be rejected.
If there is not a sufficient value to meet the specified amount requested, the maximum available amount will be withdrawn.
1
Page 1 of 4
Form 140 (5/15) 15-05-039A

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