Insurance Assumption Life Surrender Form

INSURANCE ASSUMPTION LIFE SURRENDER FORM

Use this form to submit a formal request by an Assignee/Applicant to assume ownership of a life insurance policy and to elect surrender of that policy for its cash surrender value. Submission of this form constitutes a representation that the Assignee/Applicant has the legal authority to request assumption and/or surrender. The insurer's acceptance of an assumption or surrender request is subject to verification, approval, and any contractual surrender provisions.

1. POLICY INFORMATION

2. CURRENT POLICYOWNER

3. ASSIGNEE / APPLICANT (Person Requesting Assumption / Surrender)

4. INSURED (If different from Applicant)

5. ELECTION: ASSUMPTION / SURRENDER OPTIONS

The Applicant elects (select one or more as applicable). Applicant understands that election to assume the policy creates ownership obligations and that election to surrender terminates the policy and may be subject to surrender charges and tax consequences.

I elect to assume ownership of the policy and accept all rights, liabilities, and conditions of the policy contract effective upon insurer approval.

I elect to surrender the policy in full for its cash surrender value, after offset for any outstanding loan balance and surrender charges.

I elect a partial surrender in the amount:

I elect to assume the policy but retain it in force and request a policy change as described in the remarks section below.

Check payable to Assignee/Applicant

Check payable to Current Policyowner

Direct deposit to bank account (complete details below)

6. BENEFICIARY INFORMATION (If proceeds to be paid to beneficiary)

7. REQUIRED DOCUMENTATION CHECKLIST

The following documents must be submitted with this form. Check each box for documents included with this submission.

Original policy document or certified copy

Proof of identity (government-issued photo ID)

Executed assignment or transfer instrument (if applicable)

Recent policy loan statement (if loan exists)

Death certificate (only if claim arises from insured's death)

8. REPRESENTATIONS, AUTHORIZATIONS, AND ACKNOWLEDGEMENTS

By signing below, the Applicant represents and warrants that the Applicant is the lawful Assignee or has been duly authorized by the current policyowner to request assumption and/or surrender of the policy identified in Section 1. Applicant certifies that all statements made in this form and in any supporting documentation are true, complete, and correct to the best of Applicant's knowledge. Applicant authorizes the insurer to obtain and release information necessary to process this request, including underwriting, policy, and financial records.

Applicant acknowledges that surrendering a policy may result in surrender charges, reduction for outstanding loans, and potential tax liability. Applicant agrees to hold the insurer harmless for obligations arising from acceptance of an assumption or surrender request made in reliance on documents and representations submitted with this form.

I have read and understand the representations, authorizations, and potential tax and financial consequences described above.

9. DECLARATION AND CERTIFICATION

I declare under penalty of perjury, under the laws of the applicable jurisdiction, that the information provided on this form is true and correct, that I am authorized to request the action(s) indicated, and that I will provide any further documentation reasonably requested by the insurer to verify my authority or the facts stated herein. I understand that knowingly providing false information may constitute insurance fraud and subject me to civil and criminal penalties.

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