Insurance Life Servicing Form

INSURANCE LIFE SERVICING FORM

Client Name:    Policy Number:    Insured Name:

Applicant / Insured Information

Policy Details

Policy Type: Term Whole Life Universal Life Variable Life Other:

Servicing Request

Select the servicing action(s) requested. Provide supporting documentation as indicated below.

Change of Address    Change of Owner    Change of Beneficiary

Change Premium Payment Method    Premium Payment Suspension / Deferment    Policy Loan

Partial Surrender    Full Surrender / Cancellation    Reinstatement Request

Beneficiary Designation

Primary Beneficiaries (designate percentage shares that together equal 100%)

Contingent Beneficiaries

Coverage, Riders and Exclusions

Select applicable riders or coverage features:
Accidental Death Benefit    Waiver of Premium    Child Rider    Accelerated Death Benefit    Return of Premium    Other:

This policy may contain contestability, suicide and misstatement provisions, limitations for hazardous activities, exclusions for illegal acts, and other restrictions set forth in the policy contract. Requesting a change may alter policy guarantees, premiums, or available benefits. Describe any requested exception or special instruction below.

Documentation Checklist

Please attach or provide copies of all applicable documentation. Check items provided:

Proof of Identity (government‑issued ID)    Death Certificate (for claim/change)    Assignment / Transfer Documents

Power of Attorney (if applicable)    Trust Documents    Medical Records (if required)

Declaration, Authorization and Certification

I, the undersigned Applicant/Policyowner, declare under penalty of perjury that the information provided on this form is true and complete to the best of my knowledge. I authorize the insurer and its representatives to rely upon and effect the changes requested herein. I certify that I am authorized to make the requested changes and that any beneficiary designations or ownership changes appearing on this form supersede prior designations to the extent permitted by the policy contract.

I consent to the insurer obtaining, releasing or exchanging information (including medical, financial and transactional records) to or from medical providers, financial institutions, legal representatives, and other insurers as reasonably necessary to process this request. I understand that certain servicing changes may have tax or other legal consequences and that the insurer does not provide tax or legal advice.

I acknowledge that misstatements, omissions, or fraudulent submissions may result in denial of the requested change, rescission of coverage, imposition of penalties, or referral for criminal prosecution where permitted by law. I agree to indemnify and hold harmless the insurer for actions taken in good faith on the basis of this form and accompanying documentation.

Signature and Authorization

By signing below, I authorize the insurer to implement the servicing instructions contained in this form and certify that all attached documents are true and complete copies of the originals. I understand that the insurer may require additional documentation prior to effecting certain changes and that processing times vary.

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