Insurance Surrender Request

INSURANCE SURRENDER REQUEST

Client Name:    Policy Number:

Applicant / Insured Information

Policy Details

Policy Issue Date:    Policy Type:

Surrender Request and Options

Select surrender option(s) requested (check all that apply):

Payment / Disbursement Instructions

Select method for disbursement of surrender proceeds (select only one):

Beneficiary Information

Complete beneficiary details as recorded or to confirm potential claim handling. If beneficiaries are irrevocable, written consent is required before surrender will be processed.

Documentation Checklist

Provide the following documents as applicable. Check to indicate included items:

Declaration, Authorization and Acknowledgement

I hereby request the insurer to surrender the policy identified above and to remit any cash surrender value in accordance with the policy provisions. I acknowledge that surrendering the policy may result in loss of death benefit, loss of any guarantees, surrender charges, outstanding loan offsets, and possible tax consequences. I certify that all information provided on this form is true, accurate and complete to the best of my knowledge.

I authorize the insurer, its agents and service providers to obtain, review and disclose information necessary to process this request, including but not limited to medical, financial and policy records. I authorize the insurer to deduct any outstanding policy loans, interest, fees, and applicable surrender charges from the surrender proceeds prior to disbursement.

I understand that if the beneficiary designation is irrevocable, the insurer will not process this surrender without the required beneficiary consent. I agree to indemnify and hold the insurer harmless for any payments made in accordance with this authorization and representations.

Agent / Representative (if applicable)

Certifications and Notices

By signing below I certify under penalty of perjury that I am the owner of the policy or an authorized representative with full legal authority to request this surrender, that all information provided is correct, and that I understand the financial and tax consequences of surrender. I understand the insurer may require additional documentation and that processing may be delayed until all required items are received.

I warrant that no assignment of the policy exists that would prevent this surrender unless such assignment and assignmentholder consent are provided. I agree the insurer may rely on the representations in this form in processing the surrender request.

Sign Now