Insurance Surrender Voucher

Insurance Surrender Voucher

Insurer and Voucher Reference

Insurer Name:

Date of Request:

Insured / Policyholder Information

Date of Birth:    Social Security / Tax ID:

Policy Details

Policy Number:    Policy Type:

Term Whole Life Universal Life Variable Life

Surrender Calculation (Amounts in U.S. Dollars)

Effective Surrender Date:

Coverage Election and Options

By completing this voucher the policyholder elects to surrender the policy in full. The following options are selected (select applicable):

Receive cash surrender value Partial surrender (amount below)

Payee and Disbursement Instructions

Payment Method:

Check mailed to payee address ACH deposit Wire transfer

Beneficiary Information

Supporting Documentation Checklist

The following documents are provided with this voucher (check all enclosed):

Original policy document Assignment(s) or endorsements Government-issued ID Medical records (if applicable)

Exclusions and Adjustments

This voucher does not constitute payment. Payment of surrendered value is subject to verification of identity, satisfaction of any outstanding indebtedness under the policy (including accrued interest), completion of required documentation, and validation of ownership and beneficiary designations. The insurer reserves the right to apply offsets for outstanding loans, lienholders, or valid assignments. Surrenders resulting from misrepresentation, fraud, or material non-disclosure may be rescinded in accordance with policy provisions.

Reason for Surrender

Certification and Authorization

By signing below, the undersigned certifies that they are the lawful owner or authorized representative of the policy identified above and that all information submitted on this voucher is true, complete, and correct to the best of their knowledge. The undersigned authorizes the insurer to pay the net surrender proceeds as indicated, to deduct any outstanding indebtedness, policy loans, accrued interest, surrender charges, and applicable taxes or withholdings, and to release the policy from further liability upon payment. The undersigned acknowledges that surrender may have tax consequences and agrees to indemnify the insurer for any liability arising from inaccurate payee information or failure to disclose encumbrances.

The undersigned further acknowledges receipt of the required policy disclosures and confirms that no other person has an equal or superior right to the proceeds except as disclosed in this voucher or identified by supporting documentation.

Acknowledgment of Rights and Release

Upon acceptance of this surrender request by the insurer, the policy will be terminated and no further benefits will be payable under the policy. The undersigned releases the insurer, its subsidiaries, agents, and employees from any further obligation with respect to the surrendered policy except for payment in accordance with this voucher and policy terms.

Signature

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