Request to Surrender Policy

Request to Surrender Policy

Not for use with Qualified Plan and Keogh (H.R. 10) Plan Owned Policies

Use this form for all life insurance cash surrenders, excluding Qualified Plan and Keogh (H.R. 10) Plan owned policies. Do not complete this request to surrender the policy without understanding the implications. Once the surrender is processed, the policy and insurance coverage will be terminated. The policy cannot be reinstated once it has been surrendered, unless required by law.

A Policy Information

1. Policy number(s) (If group policy, indicate group number & name):

2. Insured(s) full legal name (First, MI, Last, Suffix):

B Owner Information

1. Full legal name:

2. Taxpayer Identification Number (SSN/ITIN/EIN):

3. Phone number:
  Extension:  Home Work Cell

Receive a text message regarding the status of this request.
By checking this box, you agree to receive text messages regarding this request to your mobile phone.

4. Email address:

Receive an email regarding the status of this request.

5. Is this Policy subject to a divorce obligation?
Yes No (Default)

6. Is this Policy collaterally assigned?
Yes No

If Yes, complete assignee information below.

Individual(s) → Print individual’s full legal name (First, MI, Last, Suffix):

Corporate Entity → Print Entity name:

Trust → Print full name & date of Trust (mm/dd/yyyy):

C Mailing Information

1. Payee (Select one):
Owner (Default) Assignee

2. Mailing address (PO Box or Street, Apt. or Suite #, City & State or Country, ZIP/Postal Code):

3. Delivery method (Select one):
U.S. Postal Service (Default – no charge; allow 10 business days for normal delivery) FedEx/UPS Priority

a. Account type (Select one): FedEx UPS Priority

b. Account number:

c. Associated ZIP/Postal Code:

D Policy Surrender Information

1. Did the Agent/Broker recommend this surrender?
Yes No

2. Pay the proceeds (Select one):

As a cash payment

To a new MassMutual policy

Toward an existing MassMutual policy

Policy number:

Apply to premium: $

Apply to loan interest: $

Apply to loan principal: $

To a new replacing company (non-MassMutual) under an External 1035 exchange

a. New non-MassMutual policy (If group policy, indicate group number & name):

b. Will there be carryover of an existing policy loan, if product allows?
Yes No

Loan amount: $

c. Payee full legal name:

d. 1035 mailing address (PO Box or Street, Apt. or Suite #, City & State or Country, ZIP/Postal Code):

Partial return of rider premium

Reduced paid-up LTC coverage

E Withholding Election

Do not withhold   Withhold 10%

F Disclosures

Important Information Regarding Surrenders. In consideration for payment of the surrender value, the undersigned releases all right, title and interest in the policy and agrees to hold the Company harmless from any and all claims, actions, causes of action, suits, and liabilities in connection with the policy.

Tax Warning. Upon surrender, you must include in gross income any gain that has accumulated in your policy. If your policy carries a loan, the amount you must include in gross income could be much higher than the net payment you actually receive.

Section 1035 Exchange. If this surrender is part of a Section 1035 exchange for a policy to be issued by another insurance company, this surrender form must be signed by an officer of the other insurer.

G Agreements & Signatures

Taxpayer Identification: By my signature, I, the Owner, certify under penalties of perjury that the number shown in section B is my correct Taxpayer Identification Number.

H Notary Stamp/Seal

A Notary stamp/seal is required for the Owner and Joint Owner if the distribution is greater than $100,000 and one of the following applies: (1) proceeds are sent to an address other than the address of record; or (2) proceeds are sent to an address that has been changed in the past 90 days.

On personally appeared before me and is known to me and/or satisfactorily proved to me to be the person who signed this document.

Signature of Notary Public:

State/County where signed:

My commission expires:

I Submission Instructions

For more information or general questions, use the resources below or visit www.massmutual.com. Once you have reviewed and completed this form, return pages 1-4 for processing.

Phone: 1-800-272-2216 Monday through Friday, 8 a.m. – 8 p.m. Eastern Time

Mail: MassMutual, Attention: Life Hub, 1295 State Street, Springfield, MA 01111-0001

Fax: Attention: Life Hub, 1-866-329-4527

Signature Guidelines

Use these guidelines to determine signature and title requirements for all products and forms. If you have additional questions regarding signature requirements, contact the MassMutual Service Center.