Life Surrender Form - Great American Insurance Group printable pdf download

Policy Number: ________________

Insured: ______________________

Owner: _______________________

I hereby apply for the cash surrender value of the above policy. In consideration of the payment to be made to me of the cash surrender value, I

herewith surrender the policy to the Company for cancellation of all insurance thereunder and hereby release and forever discharge the Company

from all claims under said surrendered policy. The election to surrender the policy shall not be effective until this application and the policy (or

suitable evidence of lost policy) are received by the Company at the Home Office in Cincinnati, Ohio, and when so received, the Company’s

liability under said policy, except for the amount of cash value, shall cease.

Dated at ________________________ _______________________ this ______ day of _______________________, 20_____.

(City)

(State)

_______________________________________________

______________________________________________

Policyowner (Written Signature)

Social Security Number (Policyowner)

_______________________________________________

________________________________________________

Policyowner’s Spouse (Written Signature – If applicable)

Date

Please note if you are in a Community Property State (AZ,CA,ID,LA,NV,NM, WA,WI), we will need the

policyowner’s signature and the policyowner’s spouse signature.

NOTICE OF WITHHOLDING ON DISTRIBUTIONS OR WITHDRAWALS

The distributions you receive from the above policy are subject to Federal Income Tax withholding and state Income Tax withholding, where

applicable, unless you elect not to have withholding apply. You may elect not to have withholding apply to your distribution by checking the

appropriate box below and returning it to our office.

If you do not respond by the date your distribution is scheduled to be made, Federal Income Tax and State Income Tax, where applicable, will be

withheld from the taxable portion of your distribution.

If you elect not to have withholding apply to your distribution payments, you may be responsible for payment of estimated tax. You may incur

penalties under the estimated tax rules if your withholding and estimated tax payments are not sufficient.

ELECTION FOR PAYEE OF NON-PERIODIC PAYMENTS



I have read the above information and I DO NOT want to have Federal Income and State Income Taxes, where applicable, withheld

from my distribution.



I have read the above information and I DO want to have Federal Income and State Income Taxes, where applicable, withheld from

my distribution.

Please Note: Where we have indicated that this is a tax-qualified plan, distribution of the policy proceeds may adversely affect the deferred status

of the policy. We urge you to consult your tax advisor regarding the taxation of any distribution prior to reaching a final decision regarding this

transaction.

AFFIDAVIT PERTAINING TO LOST POLICY

(Complete only if you are unable to locate your original policy)

I, ___________________________________, the undersigned, certify that I am the owner of above policy number issued or assumed by Great

American Life Insurance Company. I further certify that the policy has been lost or destroyed and I have no knowledge as to its whereabouts;

that no person or persons, corporation, or association has any claim or interest in said policy, by virtue of any sale, assignment, or pledge thereof.

I will indemnify and hold harmless Manhattan National Life Insurance Company, its successors and assigns from and against any and all

liability, loss, damages, judgments, costs, charges, counsel fees, and expenses of every nature and kind which it does sustain by reason of

accepting this statement in lieu of the actual policy. I agree that the original policy, if it later comes into my possession, shall be returned

promptly to Great American Life Insurance Company.

_______________________________________

_________________________________

Policyowner Signature (Written)

Date

Member Life Insurance and Annuities Companies:

Administration for Life Insurance and Annuities:

Annuity Investors Life Insurance Company

Central Reserve Life Insurance Company

Great American Life Insurance Company

Continental General Insurance Company

Manhattan National Life Insurance Company

Loyal American Life Insurance Company

Provident American Life & Health Insurance Company

United Teacher Associates Insurance Company

P.O. Box 5416

Cincinnati, OH 45201-5416

Toll Free: (888) 863-5891

Fax: (800) 859-0021

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Life Surrender Form - Great American Insurance Group

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