Insurance Life Surrender Form

INSURANCE LIFE SURRENDER FORM

Use this form to request voluntary surrender of a life insurance policy. Completion of this form authorizes the insurer to cancel the policy and pay any applicable cash surrender value, less outstanding indebtedness, surrender charges, and other lawful deductions. Submission of this form does not guarantee that funds will be paid prior to validation of ownership and completion of required inquiries. By signing below the applicant certifies that the information provided is true and that the applicant is authorized to request surrender.

Applicant / Insured Information

Policy Information

Policy Issue Date:

Surrender Request and Options

Effective Date Requested: . I hereby request that the policy identified above be surrendered and that all death benefits and future insurance coverage under the policy be forfeited upon processing.

Select surrender option (check all that apply):

Lump-sum cash surrender (payable after lawful deductions)

Partial withdrawal (specify amount): $

Extended term insurance

Reduced paid-up insurance

If election is inconsistent with policy terms, the insurer may apply the option that is permissible under the policy.

Outstanding Indebtedness and Deductions

I authorize the insurer to deduct any outstanding policy loan balance, accrued interest, surrender charges, and other lawful offsets from the cash surrender value prior to payment. Provide known outstanding amounts below:

Payment Instructions

Select payment method:

Issue check payable to applicant at mailing address on file

Direct deposit to bank account (complete bank information below)

Account Type: Checking Savings

Tax Withholding and Certification

Surrender proceeds may be taxable. The applicant is responsible for determining tax consequences. Check one option below regarding withholding:

Do not withhold federal income tax

Withhold federal income tax at the statutory rate

Certification under penalties of perjury: I certify that the taxpayer identification information provided is correct to the best of my knowledge and that I am the person entitled to receive payment.

Beneficiary Acknowledgement

Surrender of the policy will terminate any designation of beneficiary for future proceeds under the surrendered policy. Provide current primary beneficiary information for insurer records:

I acknowledge that surrender cancels the policy and revokes any beneficiary designation with respect to future benefits under the surrendered policy: Acknowledged

Documentary Requirements

Attachments required for processing (check all included): Copy of policy document, Proof of identity, Power of attorney (if applicable), Other documentation (describe below).

Authorization and Certification

By signing below I authorize the insurer to cancel the policy described above and to pay any cash surrender value in accordance with the policy provisions. I authorize the insurer to release or obtain records necessary to verify ownership, beneficiary status, and entitlement to proceeds. I further authorize the insurer to apply policy loans, accrued interest, fees, surrender charges, and any other lawful offsets against the surrender proceeds prior to payment.

I certify, under penalty of perjury, that the information provided on this form is true and correct to the best of my knowledge and that I am the lawful owner or authorized representative entitled to request this surrender. I understand that surrender is generally irrevocable once processed and that tax or other financial consequences may result.

Agent / Producer Information

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