What is this form used for?

The form documents a policy's cash surrender value and encumbrances for surrenders, loans, collateral verification, tax reporting, or estate administration and serves as an auditable record for decision-makers.

Who is authorized to sign?

An authorized carrier representative, named policyowner, or a designated agent may sign; lenders may require additional attestations or verified carrier signatures depending on collateral rules.

Can this form be signed electronically?

Yes. Electronic signatures are legally enforceable under the ESIGN Act (15 U.S.C. ch. 96) and UETA in adopted states, provided intent, consent, attribution, and retention requirements are met.

Is notarization or RON required?

Notarization is rarely mandated for a cash value statement itself, but some lenders or legal processes may require notarized or remotely notarized copies; RON rules differ by state and should be verified with the state notary authority.

What if values change after submission?

Valuations are effective as of the stated date; subsequent policy changes, loans, or market adjustments require a new valuation dated when the change occurred to reflect current figures.

How long should I keep signed forms?

Retain the signed form for at least the policy term plus three years; follow IRS rules (IRC §6501(a)) and industry standards such as HIPAA six-year retention where applicable.

Electronic Signature
Templates
Insurance
Insurance Cash Value Form

Insurance Cash Value Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

INSURANCE CASH VALUE FORM

Policy Owner / Applicant Name:

Insured Name (if different): Policy Number:

Insurance Company Name: Requested Valuation Date:

Applicant / Insured Information

Mailing Address Date of Birth Contact Phone Email Address

Policy Details

Policy Type: Whole Life Universal Life Variable Life Term Converted to Permanent Other

Face Amount / Coverage Limit

Premium Mode: Monthly Quarterly Semi-Annual Annual

Policy Effective Date Policy Maturity / Expiry (if applicable)

Cash Value Request

I request a statement of the following values as of the Requested Valuation Date indicated above (check all that apply):

Cash Surrender Value
Account / Account Value
Accumulation Value
Policy Loan Value / Loan Balance
Net Cash Surrender Value (after outstanding loan and fees)
Guaranteed Cash Value
Non-Guaranteed / Account Value Components
Other (describe below)

If Other, describe

Beneficiary Information

Primary Beneficiary Name Relationship and Percentage Contingent Beneficiary Name (if any) Relationship and Percentage

Purpose of Request & Documentation

Purpose (check one or more): Collateral Assignment Policy Loan Application Surrender Consideration Estate Settlement Sale/Transfer of Policy Other

Documentation Provided: Copy of Policy Assignment Form Power of Attorney Proof of Identity Other Documents

If Other, describe

Exclusions, Limitations & Fees

The insurer's response will reflect only amounts contractually established by the policy as of the valuation date requested. Amounts reported do not constitute an instruction to surrender policy benefits, nor do they alter ownership or beneficiary designations. The insurer may deduct applicable policy loan balances, outstanding premiums, surrender charges, policy administration fees, and any required taxes prior to disbursal. The insurer may refuse to provide values until satisfactory identity and authority documentation has been received.

Certification and Authorization

By signing below, I certify under penalty of perjury that the information provided on this form is true, correct, and complete to the best of my knowledge. I authorize the insurer and its agents to release the requested policy valuation information to the policy owner/applicant and any third party named in associated documentation for purposes stated above. I agree to indemnify and hold the insurer harmless for disclosures made in good faith pursuant to this authorization. I acknowledge that any quoted values are subject to final verification and adjustment by the insurer and that the insurer may impose a reasonable fee for preparation of an official valuation statement.

I acknowledge that this request does not itself constitute a request to surrender or assign the policy unless explicitly indicated by me in writing below.

I hereby request that the insurer (check if surrender or assignment requested)

Process surrender of the policy as requested in accompanying documentation
Process collateral assignment as requested in accompanying documentation

Insurer Use Only

Date of Calculation Calculated Cash Surrender Value Outstanding Policy Loan Balance Net Cash Surrender Value (after deductions) Guaranteed Cash Value Component Non-Guaranteed / Account Component Preparation Fee (if applicable) Insurer Notes / Calculation Details Prepared By (Insurer Representative)

Applicant Printed Name:

Signature:

Date:

What the Insurance Cash Value Form Is

An Insurance Cash Value Form documents the cash surrender value, loan balance, and net cash available under a permanent life insurance policy at a specific valuation date. Carriers, policyholders, and third parties use it to confirm current monetary value for loans, surrenders, collateral assignments, tax reporting, or estate planning. The form typically lists policy identifiers, policyowner and insured details, dates, calculation breakdowns, and signatures authorizing release of the valuation. Accurate completion reduces processing delays and supports downstream actions such as payout, lien release, or beneficiary distribution.

Why the Insurance Cash Value Form Matters

The form provides a single, auditable record of a policy's cash value and encumbrances that insurers, lenders, and beneficiaries rely on to calculate payouts, determine collateral, and meet reporting requirements under contract and tax rules.

Who Completes and Receives This Form

The completed form creates a clear chain of information used by multiple parties for financial, legal, and tax decisions.

Insurance agents and carriers who prepare official valuations for internal records or customer requests.
Policyowners and beneficiaries who request values for surrenders, loans, or estate planning purposes.
Financial institutions and lenders who verify collateral values for loans secured by life insurance.

Core Components of a Professional Insurance Cash Value Form

A professional form is concise, itemized, and auditable so recipients can verify calculations, dates, and authorization without additional back-and-forth.

Policy ID

Unique policy number and issue information so carriers and payers reliably match the valuation to the correct contract and record.

Insured Details

Full legal name, date of birth, and relationship to policyowner to remove identity ambiguity and support tax or estate processes.

Valuation Date

The exact MM/DD/YYYY date the cash value was calculated; this date affects loans, surrender charges, and tax reporting.

Cash Value Breakdown

Line-item calculations showing gross cash value, surrender charges, outstanding loans, and net cash available for clarity and auditability.

Authorization

Signature, printed name, title, and date from an authorized representative attesting to the accuracy of the valuation and release of information.

Supporting Notes

A short remarks field for special conditions, riders, market-value assumptions, or contingent liabilities that affect the stated cash value.

Required Fields at a Glance

Policy Number: Exact policy identifier

Insured Name: Full legal name

Valuation Date: MM/DD/YYYY

Gross Cash Value: Dollar amount

Loans Outstanding: Dollar amount

Authorized Signer: Name and title

Penalties and Risks of Incorrect or Missing Information

Tax Consequences: Incorrect reporting can affect taxable gain calculations

Claim Denial: Incomplete forms may delay or deny payouts

Loan Miscalculation: Errors can misstate collateral and loan limits

Legal Challenge: Ambiguous signatures invite disputes

Regulatory Penalty: Noncompliance with disclosure rules risks enforcement

Processing Delay: Missing fields increase review time

Common Preparation Mistakes to Avoid

Using an informal name or nickname instead of the policyowner's full legal name, which can prevent document matching and slow processing.
Failing to state the valuation date clearly or using an inconsistent date format, which can change loan eligibility or surrender calculations.
Omitting outstanding loan balances or rider charges, causing net cash calculations to be materially inaccurate for lenders or beneficiaries.
Not obtaining an authorized representative's signature or failing to indicate their title, which can lead to rejection or verification requests.

Step-by-Step: Filling Out the Insurance Cash Value Form

Follow these steps in order to create a clear, accurate valuation that meets insurer and third-party requirements.

01

Gather Documents: Collect policy, rider paperwork, and loan statements before you start.
02

Record Identifiers: Enter policy number and insured details exactly as shown on policy documents.
03

Calculate Values: List gross value, surrender charges, loans, and compute net cash available.
04

Sign and Date: Authorized representative signs and dates; retain a copy for records.

Where to Submit the Completed Form

Submission routes depend on the purpose: insurer records, loan collateral verification, beneficiary claims, or third-party requests.

Primary Carrier: Send to the policy's issuing carrier for official recording and payout processing.
Lender or Bank: Provide valuation when the policy secures a loan or serves as collateral.
Beneficiaries: Share with beneficiaries or estate representatives for distribution planning or claims.
Third-Party Request: Deliver to attorneys, tax preparers, or fiduciaries who require an official cash value statement.

How to Customize an Online Cash Value Form Workflow

Set up a digital template with validation, authentication, and storage rules to reduce errors and accelerate processing.

Field	Configuration
Template	Create a reusable, locked template to preserve field order and formula fields.
Conditional Fields	Show loan fields only when a loan balance is present to simplify the form.
Authentication	Require email, SMS code, or stronger identity proofing for authorized signers.
Storage	Archive signed PDFs with audit trails in secure document storage.

Digital Submission and Platform Requirements

Verify that the solution preserves the signature audit trail and retention metadata required for legal and regulatory review.

File Types: PDF, DOCX accepted; final delivery usually as signed PDF
Authenticators: Email link, SMS code, or multi-factor authentication
Integrations: Connectors for storage and workflow systems

Typical Timelines, Deadlines, and Processing Expectations

Processing times vary by insurer and purpose; plan for internal review, verification, and final delivery when scheduling related transactions.

Acknowledgement Time:

Insurer typically acknowledges receipt within 7–10 business days.

Valuation Effective Date:

Valuation is valid as of the stated MM/DD/YYYY and may change after that date.

Loan Processing:

Loan or collateral updates usually post within 5–15 business days after acceptance.

Payout Timing:

Surrender or payout timelines depend on carrier rules and may require additional verification.

Record Requests:

Allow extra time when third-party verifications or legal reviews are required.

Key Milestones in the Cash Value Request Lifecycle

A typical request passes through distinct stages from initiation to archive; tracking these milestones avoids avoidable delays.

01

Request Submitted

Policyowner or authorized agent submits completed form and supporting documents.

02

Carrier Verification

Carrier validates identifiers, outstanding loans, and policy status.

03

Valuation Issued

Carrier issues the official cash value statement with an effective date.

04

Distribution/Archive

Signed copy is delivered to requestor and retained per retention policy.

Comparison: eSignature Vendor Pricing and Capabilities

Pricing and core capabilities vary; signNow is listed first for parity in pricing comparison across common vendor features.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day trial	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently Asked Questions about the Insurance Cash Value Form

Answers to common questions on completion, signatures, legal validity, and retention for the Insurance Cash Value Form.

Need help? Contact support

What is this form used for?
The form documents a policy's cash surrender value and encumbrances for surrenders, loans, collateral verification, tax reporting, or estate administration and serves as an auditable record for decision-makers.
Who is authorized to sign?
An authorized carrier representative, named policyowner, or a designated agent may sign; lenders may require additional attestations or verified carrier signatures depending on collateral rules.
Can this form be signed electronically?
Yes. Electronic signatures are legally enforceable under the ESIGN Act (15 U.S.C. ch. 96) and UETA in adopted states, provided intent, consent, attribution, and retention requirements are met.
Is notarization or RON required?
Notarization is rarely mandated for a cash value statement itself, but some lenders or legal processes may require notarized or remotely notarized copies; RON rules differ by state and should be verified with the state notary authority.
What if values change after submission?
Valuations are effective as of the stated date; subsequent policy changes, loans, or market adjustments require a new valuation dated when the change occurred to reflect current figures.
How long should I keep signed forms?
Retain the signed form for at least the policy term plus three years; follow IRS rules (IRC §6501(a)) and industry standards such as HIPAA six-year retention where applicable.

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