Form 05897-32 Request for Service - Colonial Life

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Colonial Life | REQUEST FOR SERVICE | FAX: 1-800-561-3082 | Telephone: 1-800-325-4368
Request for Service Form
FAX this form: 1-800-561-3082
From:
Or mail: P.O. Box 1365, Columbia, SC 29202
FAX this direction
Number of pages:
Please check only the boxes that apply to the service you are requesting.
Section 1
General information
(please use blue or black ink to complete this form)
Insured’s name:
DOB: _____ /_____ /________ SSN:
(As currently listed on the policy/certificate)
Address:
City:
State:
ZIP:
Telephone:
Mobile:
Email:
List all policy/certificate numbers related to this request:
(Required to process)
Employer:
£ Section 2
Name change
Previous:
Current:
Reason:
Marriage/Divorce
Correction*
Other*
£
£
£
*A copy of legal documentation is required unless your name is changing due to reason of marriage or divorce.
£ Section 3
Address change
Address:
City:
State:
ZIP:
Telephone:
Mobile:
Email:
Section 4
Premium payment method change
(select only ONE option)
1. Deduct premiums monthly from my bank account.
£
£
1st-5th
£
6th-10th
£
11th-15th
£
16th-20th
£
21st-26th
______________________________________________________
Your draft will occur on one of the dates within the range you have selected. Please include a voided check or
Signature of bank account owner
Routing #_________________________ and Account # _________________________________
£
2. Bill me directly. (
Choose one of the following)
£
Quarterly
£
Semi-annually
£
Annually
(Submit a payment 3 times your monthly premium)
(Submit a payment 6 times your monthly premium)
(Submit a payment 12 times your monthly premium)
£
3. Change to payroll deductions
(Please contact your Plan Administrator to start payroll deduction.)
Employer:______________________________________________________________
Billing control/account number:__________________________________
Section 5
Cancellation, Surrender or Policy/Certificate Change
(also complete section 8 for surrender’s only )
Cancel/surrender the policy(ies)/certificate(s)
£
(This option will cancel or cash surrender your policy(ies)/certificate(s).)
Spouse Rider
Dependent Rider (This will cancel coverage for ALL
Other (name rider)
Cancel the following riders on the
£
£
£
policy(ies)/certificate(s):
dependents.) List date of birth of youngest dependent:
________________________
(This option will cancel policy/certificate riders only.)
____________________________
(MM/DD/YYYY)
Change Two-Parent to Individual
Change Two-Parent to One-Parent
Change One-Parent to Individual
Spouse/Dependent Continuation
£
£
£
£
Provide name, date of birth (DOB) and Social Security number (SSN) for spouse/dependent(s) continuation. If more space is needed, please provide the information in Section 9.
Name:
DOB:
SSN:
Name:
DOB:
SSN:
Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. |
page 1
| ColonialLife.com | 12-15 | 05897-32
Colonial Life | REQUEST FOR SERVICE | FAX: 1-800-561-3082 | Telephone: 1-800-325-4368
Request for Service Form
FAX this form: 1-800-561-3082
From:
Or mail: P.O. Box 1365, Columbia, SC 29202
FAX this direction
Number of pages:
Please check only the boxes that apply to the service you are requesting.
Section 1
General information
(please use blue or black ink to complete this form)
Insured’s name:
DOB: _____ /_____ /________ SSN:
(As currently listed on the policy/certificate)
Address:
City:
State:
ZIP:
Telephone:
Mobile:
Email:
List all policy/certificate numbers related to this request:
(Required to process)
Employer:
£ Section 2
Name change
Previous:
Current:
Reason:
Marriage/Divorce
Correction*
Other*
£
£
£
*A copy of legal documentation is required unless your name is changing due to reason of marriage or divorce.
£ Section 3
Address change
Address:
City:
State:
ZIP:
Telephone:
Mobile:
Email:
Section 4
Premium payment method change
(select only ONE option)
1. Deduct premiums monthly from my bank account.
£
£
1st-5th
£
6th-10th
£
11th-15th
£
16th-20th
£
21st-26th
______________________________________________________
Your draft will occur on one of the dates within the range you have selected. Please include a voided check or
Signature of bank account owner
Routing #_________________________ and Account # _________________________________
£
2. Bill me directly. (
Choose one of the following)
£
Quarterly
£
Semi-annually
£
Annually
(Submit a payment 3 times your monthly premium)
(Submit a payment 6 times your monthly premium)
(Submit a payment 12 times your monthly premium)
£
3. Change to payroll deductions
(Please contact your Plan Administrator to start payroll deduction.)
Employer:______________________________________________________________
Billing control/account number:__________________________________
Section 5
Cancellation, Surrender or Policy/Certificate Change
(also complete section 8 for surrender’s only )
Cancel/surrender the policy(ies)/certificate(s)
£
(This option will cancel or cash surrender your policy(ies)/certificate(s).)
Spouse Rider
Dependent Rider (This will cancel coverage for ALL
Other (name rider)
Cancel the following riders on the
£
£
£
policy(ies)/certificate(s):
dependents.) List date of birth of youngest dependent:
________________________
(This option will cancel policy/certificate riders only.)
____________________________
(MM/DD/YYYY)
Change Two-Parent to Individual
Change Two-Parent to One-Parent
Change One-Parent to Individual
Spouse/Dependent Continuation
£
£
£
£
Provide name, date of birth (DOB) and Social Security number (SSN) for spouse/dependent(s) continuation. If more space is needed, please provide the information in Section 9.
Name:
DOB:
SSN:
Name:
DOB:
SSN:
Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. |
page 1
| ColonialLife.com | 12-15 | 05897-32
Colonial Life | REQUEST FOR SERVICE | FAX: 1-800-561-3082 | Telephone: 1-800-325-4368
Select either section 6 or 7 per policy number, NOT both.
Section 6
Policy loan
(complete section 8)
If the amount requested is more
Please select
£ I am requesting a policy loan for the following amount: $_________________________
than the available cash value,
ONE option per
we will process this request for
policy number.
£ I am requesting a policy loan for the maximum amount available.
the maximum amount available.
£ Check this box also if you are requesting information regarding repayment of your loan on your Universal Life policy.
Policy loans are available on select life policies only. Minimum loan amounts may apply as stated in your policy contract. You will receive annual interest notices until the loan
is fully repaid. For information regarding repayment of your loan, please contact us at 1-800-325-4368.
Section 7
Withdrawal/partial surrender
~
(Universal Life policy)
(complete section 8)
If the amount requested is more
Please select
£ I am requesting a policy withdrawal/partial surrender for the following amount: $______________
than the available cash value,
ONE option per
we will process this request for the
policy number.
£ I am requesting a policy withdrawal/partial surrender for the maximum amount available.
maximum amount available.
Only one policy withdrawal/partial surrender is allowed per policy year. Minimum withdrawal amounts apply as stated in your policy contract. There will be a processing fee
as stated in your policy contract. Policy withdrawals/partial surrenders are available on universal life policies only. If your policy is not a universal life policy and you request a
withdrawal, we will process the request as a policy loan.
Section 8
Tax withholding options
Election of a tax withholding option is not available for tax-qualified products. The insurer is required to withhold 20%
Choose one of the following options.
of any recognized gain for tax-qualified products unless proceeds are rolled directly into an IRA or other qualified
If an option is not selected, a withholding
retirement plan.
will automatically be made.
Under certain criteria established by the Treasury Department, a gain may be reportable by the insurer at the time
of surrender, partial surrender or withdrawal of this policy, creating a taxable situation. However, any gain is taxable
£ I DO NOT want to have Federal Income Tax
income for the current tax year.
withheld in conjunction with this surrender/
If a gain is reportable, an IRS Form 1099R will be sent to you at the beginning of the next calendar year reporting
partial surrender/withdrawal proceeds.
the recognized gain, and a copy of IRS Form 1099R will be sent to the IRS. If a gain is not reportable when the
surrender, partial surrender or withdrawal is processed, an IRS Form 1099R will not be sent. In addition, if a gain is
£ I DO want to have Federal Income Tax
reportable, the insurer is required to withhold 10% of any recognized gain, unless the policy owner elects not to
withheld in conjunction with this surrender/
have the tax withheld. You may be subject to penalties under the estimated tax payment rules if you elect not to have
partial surrender/withdrawal proceeds.
tax withheld and payments of estimated tax and other withholding are not adequate to satisfy tax liability.
Section 9
Other requests or remarks
Section 10
Signatures required
(this section MUST be complete in order for us to process your request)
Special notice for Residents of a Community Property State: A spouse or former spouse may have an interest in life insurance proceeds or any accumulated cash value
if the policy premiums were paid with community funds. It is your responsibility to consult your legal advisor to 1) ensure that any required consent from a spouse or former
spouse has been received and 2) ensure that your spouse or former spouse will not be able to make a claim against any policy values and/or the proceeds in the event any
policy benefits become payable.
I have carefully read this request and agree that it is properly and fully completed. I understand that this request is subject to the provisions and conditions of the policy/
certificate and that the company may require additional information or requirements. I certify that the policy/certificate is not pledged or assigned to any other person
or corporation, except where stated in the request, and that no proceedings or bankruptcy or insolvency have been filed or are now pending. I certify the Social Security
number and date of birth indicated are correct, and I hereby authorize Colonial Life to execute this request.
______________________________________________________________________________
___________________________________________
Policy/certificate owner’s signature
Date
(MM/DD/YYYY)
Assignee’s signature (if any):
Date
:
(MM/DD/YYYY)
Policy/certificate owner’s
Print name:
SSN:
DOB: ____ /____ /_______
information
Address:
City:
State:
ZIP:
Telephone:
Email:
Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. |
page 2
| ColonialLife.com | 12-15 | 05897-32

Download Form 05897-32 Request for Service - Colonial Life

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