Insurance Surrender Document

INSURANCE SURRENDER DOCUMENT

Applicant / Insured Information

Policy Details

Insurer Name:

Policy Number:     Policy Type:

Issue Date:     Face Amount: $

Current Cash Surrender Value (as reported): $     Outstanding Policy Loan: $

Surrender Election

I hereby elect to surrender the above-referenced policy. Select only one option below:

  Full surrender and termination of policy

  Partial surrender (indicate amount) — $

  Request for reduced paid‑up insurance or other non‑forfeiture option (describe below)

Requested Effective Date of Surrender:

Estimated Settlement Calculation

Surrender Charge (if applicable): $     Net to Payable Before Taxes: $

Federal/State Withholding Election: No withholding    Withhold federal tax    Withhold state tax

Estimated Tax Withheld: $     Net Payable After Withholding: $

Payment Instructions

Pay settlement to (select one):

  Policy Owner / Applicant      Primary Beneficiary      Other (specify below)

  Check mailed to mailing address      ACH direct deposit (enter banking information)

Beneficiary Information

Primary Beneficiary:

Contingent Beneficiary (optional):

Documentation Checklist

The undersigned shall deliver the following documents as conditions precedent to processing this surrender. Check all items enclosed:

  Original policy document (certificate)

  Proof of identity (government ID)

  Release of assignment or lender consent (if policy encumbered)

  Original signed surrender form (this document)

  Additional supporting documentation (list below)

Declarations, Authorizations and Acknowledgements

By executing this Insurance Surrender Document, Applicant represents and warrants that Applicant is the lawful owner of the policy, has full authority to surrender the policy, and there are no outstanding legal impediments, assignments, or pledges except as disclosed herein. Applicant authorizes the insurer to cancel the policy and to apply any outstanding policy loan, interest, and surrender charges against the cash surrender value prior to disbursement.

Applicant understands and acknowledges that surrender of the policy will terminate all coverage and rider benefits associated with the policy as of the effective date of surrender, and that such surrender may have tax consequences. Applicant agrees to indemnify and hold harmless the insurer for any loss, tax liability, or penalty resulting from incorrect payee or tax election information provided by Applicant.

Applicant authorizes the insurer, its agents, and any third party engaged by the insurer to verify identity, ownership, and any information necessary to process this surrender. Applicant further authorizes the insurer to endorse and negotiate, on Applicant's behalf, any instrument issued in payment of the surrender proceeds and to release the insurer from further liability upon payment in accordance with the insurer's normal procedures.

If this policy is subject to a collateral assignment, Applicant acknowledges that the insurer may require written consent of the assignee or may remit proceeds to the assignee to satisfy the secured obligation. Applicant agrees to provide any required third‑party consents prior to processing.

Certification

I certify, under penalty of perjury, that the information provided on this document is true, complete and correct to the best of my knowledge. I acknowledge that submission of false information may subject me to civil or criminal penalties. I understand that acceptance of this surrender by the insurer is subject to verification and approval in accordance with the insurer's policies and applicable law.

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