Insurance Ballot Form

INSURANCE BALLOT FORM

Insured Name:    Policy Number:

Policyholder Information

Policy Details

Ballot Items

Voting instructions: Each policyholder entitled to vote must mark one box for each resolution. Marking multiple options for the same resolution may render that resolution vote invalid. Abstentions will be recorded as such. By submitting this ballot the policyholder certifies eligibility and authorizes the insurer to rely on this vote for corporate or policy action described below.

Beneficiary Information (if affected)

If Resolution C is approved and you instruct the insurer to process a beneficiary designation change, complete the information below. Completion of this section constitutes a policyholder instruction contingent on passage of the relevant resolution and successful verification by the insurer.

I instruct the insurer to implement the beneficiary designation recorded above if Resolution C is approved and verification requirements are satisfied.

Exclusions and Notices

This ballot is limited to the matters described in the ballot package. A vote in favor of any resolution does not itself amend the insurance contract until the insurer completes any required administrative steps and, where applicable, obtains required regulatory approvals. The insurer is authorized to rely on the representations made herein for purposes of implementing approved changes. False statements made in this ballot may subject the signer to civil or criminal penalties under applicable law.

Acknowledge receipt of exclusions: I acknowledge that I have reviewed the exclusions and limitations applicable to the proposed actions.

Documentation Checklist

Attach copies of the following as applicable:

Copy of government-issued photo identification

Proof of policy ownership or certificate

Signed authorization letter (if submitting on behalf of owner)

Declaration and Certification

By signing below I certify, under penalty of perjury to the fullest extent permitted by law, that I am the named policyholder or an authorized representative with authority to cast this ballot on behalf of the named policyholder; that the information provided on this form is true, accurate and complete; and that I understand that the insurer may rely on this ballot and associated instructions to take action if a resolution is approved. I consent to release of necessary information to validate my identity and entitlement to vote.

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