Personal Transamerica Document

PERSONAL TRANSAMERICA DOCUMENT

Policyholder Information

Policy Details

Action Requested

I request that Transamerica undertake the following action(s) with respect to the policy identified above. Check each requested action and complete the corresponding subsection fully. I understand additional documentation may be required to effect certain changes.

Representations, Authorizations, and Indemnity

By signing below, I certify that I am the lawful owner of the policy identified above or otherwise have full authority to request the actions indicated. I represent that the information provided on this form is true and complete to the best of my knowledge. I authorize Transamerica and its agents to rely upon the instructions contained herein and to take any actions reasonably necessary to effect the requested changes, including obtaining documentation to verify identity or authority.

I acknowledge that Transamerica may require additional forms, proof of identity, original documents, court orders, or other supporting evidence prior to implementing certain changes. I agree to indemnify and hold Transamerica harmless from and against any claims, losses, liabilities, or expenses that arise from acting in good faith on the instructions in this document, including any payments or changes made in reliance on these instructions.

This authorization will remain in effect until Transamerica receives a later written revocation signed by me. I understand that any revocation will not affect actions taken by Transamerica prior to receipt and reasonable processing of such revocation.

I consent to the use of electronic methods to receive, transmit, and store information related to this request and to the use of my electronic signature on this form. I understand that I may withdraw consent by providing written notice, but such withdrawal will not apply to actions already taken based on prior consent.

Additional Instructions or Comments

Notary Acknowledgment (if required)

State of:    County of:

On this day of , , personally appeared before me the signer of this document, who is personally known to me or produced satisfactory evidence of identity.

Certification and Signature

I certify under penalty of perjury that the statements made on this form are true and correct. I understand that submitting false information may subject me to civil or criminal penalties under applicable law.

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