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    V167 - Life Policy Transaction Form - Multi-Purpose

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    Kathryn Raskin
    This document is a life insurance policy transaction request form. It allows policy owners to request various transactions, including cash loans, dividends withdrawn, cash surrenders, nonforfeiture options, and changes to payment modes or dividend options. The form requires signatures to authorize the requested transactions and agrees to the transaction terms, such as releasing the company from liability for cash surrenders. It also collects identifying information, like taxpayer identification numbers, to process certain transactions.

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    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    V167 - Life Policy Transaction Form - Multi-Purpose

    Uploaded by

    Kathryn Raskin
    757 views2 pages
    This document is a life insurance policy transaction request form. It allows policy owners to request various transactions, including cash loans, dividends withdrawn, cash surrenders, nonforfeiture options, and changes to payment modes or dividend options. The form requires signatures to authorize the requested transactions and agrees to the transaction terms, such as releasing the company from liability for cash surrenders. It also collects identifying information, like taxpayer identification numbers, to process certain transactions.

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    This document is a life insurance policy transaction request form. It allows policy owners to request various transactions, including cash loans, dividends withdrawn, cash surrenders, nonforfeiture options, and changes to payment modes or dividend options. The form requires signatures to authorize the requested transactions and agrees to the transaction terms, such as releasing the company from liability for cash surrenders. It also collects identifying information, like taxpayer identification numbers, to process certain transactions.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    757 views2 pages

    V167 - Life Policy Transaction Form - Multi-Purpose

    Uploaded by

    Kathryn Raskin
    This document is a life insurance policy transaction request form. It allows policy owners to request various transactions, including cash loans, dividends withdrawn, cash surrenders, nonforfeiture options, and changes to payment modes or dividend options. The form requires signatures to authorize the requested transactions and agrees to the transaction terms, such as releasing the company from liability for cash surrenders. It also collects identifying information, like taxpayer identification numbers, to process certain transactions.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    H.O.

    USE ONLY
    Eff. Policy Received
    The Guardian Life Insurance Company of THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (“Guardian”)
    America THE GUARDIAN INSURANCE & ANNUITY COMPANY, INC. (“GIAC”)
    Administrative Office:
    Individual Markets Service & Administration BERKSHIRE LIFE INSURANCE . COMPANY OF AMERICA (“Berkshire”) Agency #
    3900 Burgess Place (Check one) Call 1-800-441-6455 from 8:00 a.m. to 6:00 p.m. Eastern Time
    Bethlehem, PA 18017 Notified On
    Policy No (s). Life Policy Transaction Request
    Requests on more than one policy must be identical/or if signatures are required
    and the owners are different, use separate forms. On pension cases attach a list of
    the policy numbers/names. Do not send the policy except for cash surrender.
    Form Submitted by: Name Phone# ( ) -
    Insured (Print): Last First Initial Agency Date

    Mail Check to Policyowner at Following Address:


    Check Here if New Address

    Cash Loan (Check One Only) (Sign on page 2)


    Maximum Check for $
    Include Dividend Lien Deduct Payment Due
    Dividends Withdrawn (Sign on page 2)
    All Deduct Payment Due
    Premium Due on Policy Check for $
    Conditional Receipt No. Send with Life Application
    Withdrawal of PUA and/or PUI (Sign on page 2)
    All Check for $
    Premium Due on policy Repay Loan
    Cash Surrender (Sign page 2) TAXPAYER IDENTIFICATION NUMBER REQUIRED
    To Policyholder: Return By in order for values quoted on attached to apply The Policy(ies) must be returned
    Policy Attached Policy Lost
    Nonforfeiture (Sign on page 2) TAXPAYER IDENTIFICATION NUMBER REQUIRED
    Paid-up Extended Term Insurance Reduced Paid-up Insurance
    For RUP: Keep Dividends Outstanding Keep Loan Outstanding
    Payment By: Minimum Deposit/Premium Loan (Sign on page 2)
    Minimum Deposit Premium Loan (Automatically Includes Dividend Lien if Needed)
    Check Attached for $
    Minimum Deposit Premium Loan, and Dividend Withdrawal
    Payment Due On Policy No.
    Change Mode of Payment To: (Change will be effective on next due date)
    Annual Semi-Annual Quarterly GOM
    Send request to Individual Markets Service & Administration, if requesting change to GOM.
    Submit R-223/void check and enough monies to the current month plus one additional month
    Change Future Dividend Option To: (Sign on page 2)
    A-Cash Payment B-Reduce Premiums (not available on GOM or Allotment)
    C-Left to Accumulate at Interest Exchange of Option F to G or G to F (Sign on page 2)
    D-Purchase Paid-up Life Additions (not available on Term Policies) U – Loan Repayment
    Also transfer all existing Dividend Accumulations to Paid-up Additions. (If Accumulations exceed $5,000 use form
    V-77 Page 1 & 2 and sign on Page 3 and send to Individual Markets Service & Administration.
    To cancel Options E. F, G, J, P, L, Q: Sign on page 2 and return Rider, Change Div. Opt To:
    OPT S – Use future dividends, any dividends at interest, and any dividend or PUA rider to pay all future premiums, if possible.
    Repayment of Policy Loan
    Check(s) Attached for $
    Use Dividends All or $ Apply to above Policy(ies)
    Use Dividends All or $ Apply to Policy No. (sign on page 2)
    Automatic Premium Loan Provision Add Cancel (sign on page 2)
    Remarks or Special Instructions

    Page 1 of 2 V-167 (9/02)


    Transaction Agreement
    For a Policy Loan:
    It is agreed that the loan(s) requested on the reverse side are subject to all the conditions and
    provisions in the policy(ies).

    For Surrender:
    It is agreed that upon payment of cash value of the policy(ies) the Company is released from
    any further liability. Each of the undersigned, for himself, his executors, administrators or as-
    signs, hereby binds himself fully to protect the Company and serve it harmless from any and
    all claims or demands under the policy(ies) except for the cash value.

    For Nonforfeiture Option:


    It is agreed that the nonforfeiture action for the policy(ies) will be according to the policy
    provisions and that any provision for Automatic Premium Loan under this policy(ies)
    is now cancelled.

    NOTE
    The Policy(ies) cannot be Surrendered or put on Nonforfeiture Option without the
    Taxpayer Identification Number.
    The undersigned authorizes the transaction(s) requested and also agrees to the Transaction
    Agreement. It is also warranted that no proceedings in bankruptcy/insolvency are pending
    against any of the undersigned and that there is no assignee/receiver of their property for the
    benefit of creditors under any voluntary or involuntary assignment, transfer, or otherwise.

    TAXPAYER ID NUMBER/SOCIAL SECURITY NUMBER DATE PRINT NAME OF OWNER OR CORPORATE OWNER OR
    ASSIGNEE OR PENSION PLAN

    OWNER SIGNATURE (INSURED IF NO OTHER OWNER) DATE OFFICER & TITLE (OF ABOVE CORP. OR ASSIGNEE) DATE

    IRREVOCABLE BENEFICIARY (IF ANY) DATE OFFICER & TITLE (OF ABOVE CORP. OR ASSIGNEE) DATE
    OR TRUSTEE

    Note:
    If the policy is owned by a corporation, we require the following:
    1 The full/corporate name should be shown above
    2. The signature of two officers, one of whom may be the insured, or
    3. The signature of one officer, other than the insured, with the corporate seal.
    If a policy has a Split Dollar ownership, the above corporate signatures are required plus the
    signature of the designated Split-Dollar owner.
    4. If owned by a Pension Plan, the Trustee's signature is required.
    Page 2 of 2 V-167 (9/02)

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