Insurance Surrender Legacy Form

INSURANCE SURRENDER LEGACY FORM

Insurer & Policy Information

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

Issue Date:    Effective Date:

Applicant / Insured Information

Date of Birth:    Tax ID / SSN (last 4):

Surrender Election

I hereby elect the following surrender option (select one or more as applicable and complete requested fields):

Full surrender — pay the cash surrender value, terminate policy and all riders

Partial surrender    Amount:    Remaining Policy Instructions:

Convert to paid-up policy in accordance with contract terms

Terminate all riders

Disposition of Proceeds

Payment To: Policy Owner Current Beneficiary(ies) Estate

Electronic Transfer (optional): Bank Name: Routing #: Account #:

Outstanding Loans / Liens

Is there an outstanding policy loan or assignment? Yes No

Beneficiary Information

List primary beneficiaries (percentages must total 100%). If more space is required, attach additional sheet signed and dated by the applicant.

Relationship:    Percent: %

Relationship:    Percent: %

Relationship:    Percent: %

Documentation Checklist

The following documents are required to process this surrender. Check those attached now:

Original policy document

Assignment or lien release documentation

Voided check or bank verification for electronic transfer

Government-issued photo identification for applicant

Additional documentation (describe below)

Exclusions, Acknowledgements & Certifications

By signing below, the Applicant certifies that they are the lawful owner of the policy or have authority to act on behalf of the owner. The Applicant acknowledges and agrees that:

1. THIS SURRENDER ELECTION IS IRREVOCABLE once the Insurer processes the election in accordance with policy terms and applicable law.
2. The Insurer may deduct any outstanding policy loan, accrued interest, surrender charges, unpaid premiums, required taxes, or other contractual offsets from the surrender proceeds.
3. If the policy is assigned, pledged, or subject to third-party interest, the Insurer may require the written consent and release of the assignee before releasing funds.
4. The Applicant understands that surrender may create tax consequences and the Insurer is not responsible for tax advice; the Applicant is responsible for reporting and payment of any taxes due.
5. The Insurer may require original policy documents, proof of identity, and other documentation prior to payment; failure to provide required documents may delay processing.
6. Payment made in accordance with the instructions on this form, or to the last recorded beneficiary when applicable, constitutes a full and final discharge of the Insurer's liability with respect to the surrendered policy.

The Applicant authorizes the Insurer and its representatives to verify any information provided, to obtain and exchange records as necessary to process this surrender, and to pay any amounts due in accordance with the instructions provided on this form. The Applicant releases and holds harmless the Insurer from any liability resulting from payment made in good faith in reliance on this instruction.

Applicant Certification

I certify under penalty of perjury that the information provided on this Insurance Surrender Legacy Form is true, complete, and correct to the best of my knowledge. I represent that I have the legal authority to execute this request and to receive the proceeds. I understand and acknowledge the terms, deductions, and potential tax consequences described above, and I agree to indemnify and hold the Insurer harmless for any loss arising from reliance on this form and the information contained herein.

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