Insurance Policy Surrender

INSURANCE POLICY SURRENDER REQUEST

Policy Owner Name:   Policy Number:

Insurer Name:   Policy Type:

Applicant / Insured Information

Policy Details and Surrender Request

Policy Issue Date:   Face Amount: $

Surrender Option: Cash surrender Partial withdrawal (specify amount) Amount: $

Alternative election (if applicable): Reduced paid‑up Extended term

Outstanding Indebtedness / Loans

Outstanding Policy Loan Balance: $   Accrued Loan Interest: $

I authorize the insurer to deduct any outstanding loan balance, accrued interest, surrender charges, and administrative fees from the surrender proceeds prior to payment.

Payment Instructions

Payment Method: Check mailed to mailing address Electronic transfer to bank account

Beneficiary Information

Primary Beneficiary Name:   Relationship:

Percentage:

Is there an irrevocable beneficiary or assignment that requires beneficiary consent to surrender? Yes No

Attachments / Documentation

Include with this request (check all that apply): Original policy document Copy of government ID Signature verification / medallion guarantee

Declaration, Authorization, and Acknowledgements

I, the undersigned Policy Owner, declare that I am authorized to surrender the policy and that the information provided in this form is true and complete to the best of my knowledge. By signing below I authorize the insurer to:

1. Terminate all coverage under the above-referenced policy as of the effective surrender date and pay any cash surrender value less applicable loans, interest, surrender charges, and fees.
2. Obtain, verify, and disclose information reasonably necessary to process this request and to the extent permitted by law release to or receive from third parties such information for claim processing and anti‑fraud purposes.
3. Offset any indebtedness or assignments against proceeds and apply funds as permitted under policy provisions and law.

I acknowledge that surrender may have tax consequences, that surrender will terminate death benefits and other policy values except as provided by alternate election selected, and that I have not relied on the insurer for tax, legal, or investment advice. I agree to indemnify and hold the insurer harmless for payments made in good faith pursuant to this request.

Certification

By signing below I certify under penalty of perjury that I am the named policy owner or legally authorized representative with full authority to request this surrender. I understand that falsification of this request may be a criminal offense.

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