Legal Policy Surrender Request

LEGAL POLICY SURRENDER REQUEST

This Legal Policy Surrender Request (the Request) is made on by Policy Owner: whose address is (Policy Owner), and Insurance Company: with principal office at concerning policy number: issued on behalf of Insured: .

RECITALS

WHEREAS, Policy Owner is the owner of the life insurance policy identified above and desires to surrender the policy in whole or in part; and

WHEREAS, Insurance Company administers the policy and maintains records of the policy's accumulated cash value, surrender charges, outstanding loans and charges; and

WHEREAS, the parties wish to set forth the terms, authorizations and releases necessary to effectuate the requested surrender and payment of any proceeds due to Policy Owner or other designated payee.

NOW, THEREFORE

1. REQUEST FOR SURRENDER

Policy Owner hereby requests that Insurance Company surrender the policy as follows (select applicable option and provide details where requested):

Full surrender — terminate the policy and pay the net surrender value.
Partial surrender — withdraw specified amount: $ on or effective as of .
Policy loan collapse / offset — apply outstanding loan balance against surrender proceeds.

2. AUTHORIZATION FOR PAYMENT

Policy Owner directs Insurance Company to remit surrender proceeds, less applicable surrender charges, loans, interest, and taxes, by the following method (select one and complete required payee information):

Check to Policy Owner or Payee on file.
Wire transfer (complete bank details below).
ACH / Direct deposit (complete bank details below).

Checking Savings

3. TAX WITHHOLDING AND REPORTING

Policy Owner understands that surrender proceeds may be subject to federal and state income tax and that Insurance Company may be required to withhold taxes and report distributions to tax authorities. Policy Owner certifies the following taxpayer information for reporting purposes:

Withhold required amounts as determined by Insurance Company.
No withholding; Policy Owner acknowledges potential tax liability and accepts responsibility.

4. REPRESENTATIONS AND WARRANTIES

Policy Owner represents and warrants that: (a) Policy Owner is the lawful owner of the policy identified herein and has full authority to request and effectuate the surrender; (b) there are no assignments, liens, or encumbrances other than those disclosed to Insurance Company in writing; (c) all information provided in this Request is true, correct and complete; and (d) execution of this Request will not violate any agreement to which Policy Owner is a party.

5. RELEASE AND INDEMNIFICATION

Upon payment of the net surrender proceeds in accordance with this Request, Policy Owner releases and discharges Insurance Company from all obligations under the policy to the extent of such payment. Policy Owner agrees to indemnify, defend and hold harmless Insurance Company from any claims arising from inaccurate information, undisclosed assignments, or third‑party claims against the policy not disclosed to Insurance Company prior to payment.

6. AUTHORIZATION TO OBTAIN AND RELEASE INFORMATION

Policy Owner authorizes Insurance Company to obtain information necessary to process the surrender, including but not limited to medical or financial records, and authorizes Insurance Company to disclose to its agents, reinsurers, and service providers information necessary to process payment. Policy Owner agrees that Insurance Company may rely upon copies of signatures, electronic instructions, or transmitted instructions and is not required to investigate the authenticity of such instructions.

7. NOTICES

Any notice required or permitted under this Request shall be in writing and delivered to the addresses set forth in the opening paragraph or to such other address as a party designates by written notice delivered in accordance with this section. Notices shall be effective upon receipt.

8. AMENDMENTS; WAIVER; COUNTERPARTS

Any amendment or modification to this Request must be in writing and signed by both parties. Failure by either party to insist upon strict performance of any provision shall not constitute a waiver of any subsequent default. This Request may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

9. GOVERNING LAW

This Request shall be governed by and construed in accordance with the laws of the state of , without regard to its conflict of laws principles.

10. ENTIRE AGREEMENT

This Request, together with any documents incorporated by reference and the policy contract, constitutes the entire agreement between the parties with respect to the surrender of the policy and supersedes all prior negotiations, understandings and agreements relating to the subject matter hereof.

11. SEVERABILITY

If any provision of this Request is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect and shall be interpreted to give effect to the intent of the parties.

CERTIFICATION

Policy Owner certifies under penalty of perjury that the information provided in this Request is true and correct, that Policy Owner is authorized to execute this Request, and that Policy Owner understands and accepts the consequences of surrender including tax and potential loss of benefits under the policy.

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