Life Cancellation Form

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AMERICAN FAMILY LIFE INSURANCE COMPANY

6000 AMERICAN PKWY
MADISON, WI 53783-0001
1-800-MY AMFAM (1-800-692-6326)
POLICY SURRENDER IN FULL – ALL LIFE INSURANCE POLICIES

SECTION 1. GENERAL INFORMATION.
Policy Number(s)
Primary Insured’s Name (first) (mi) (last) (suffix)
Owner’s Name (first) (mi) (last) (suffix) Owner’s Social Security No. (required)
Owner’s Address
City State Zip
Disbursements will be mailed to the policy owner address on file, if no new address is provided.
SECTION 2. POLICY SURRENDER IN FULL. Any applicable surrender charge will apply. Once a policy is surrendered, it cannot be
reinstated. A surrender may have tax consequences, please consult a tax advisor regarding your tax situation.
I, the Owner, hereby apply to Surrender all rights to the Policy and receive the surrender value in a lump sum, unless other instructions are
provided below:
Apply surrender value to Loan repayment on Policy No(s) __________________________________________________________
Apply surrender value as a premium payment to Policy/Contract No(s) ________________________________________________
SECTION 3. TAX WITHHOLDING ELECTION. (Required for all policies except term policies.)
The surrender proceeds are subject to federal income tax withholding unless you elect not to have withholding apply.
You may elect not to have withholding apply by completing the withholding election below. If you elect not to have withholding apply to
the taxable amount, you may be responsible for the payment of estimated taxes. There are penalties for not paying enough tax during the
year, either through withholding or estimated tax payments. It is recommended that you check with your tax advisor to determine if
withholding is necessary.
FEDERAL TAX WITHHOLDING ELECTION
If you do not choose one of the federal tax withholding options below, the Company is required by law to withhold federal
income taxes from the taxable amount at a flat 10% rate.
NO, do not withhold federal income tax.
Note: Taxes will be withheld at the applicable backup withholding rate if you have not provided us with your social security or tax ID
number (SSN/TIN).
YES, withhold _______ % of taxable amount, a minimum of 10% must be withheld.
STATE TAX WITHHOLDING ELECTION
If no election is made for state but you elect federal withholding, we will withhold if your state requires it. Note: IN, IA, MA and NC require
a separate state specific withholding form. Please call 1-866-860-8152 if you need such a form.
NO, do not withhold state income tax.
YES, withhold _______ % of taxable amount for the state of ____________ . Available for AR, CA, ID, IL, MT, NJ, and ND
STATE
L-78 (I) Page 1 of 2 Stock No. 25132 Rev. 5/15

SECTION 4. CERTIFICATIONS - SUBSTITUTE IRS FORM W-9.
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct TIN/SSN, and
2. I am not subject to backup withholding due to failure to report interest and dividend income, and
3. I am a U.S. citizen or other U.S. person (defined in the instructions of IRS Form W-9).
If you are NOT a U.S. citizen or other U.S. person, you must state the country of which you are a citizen and submit a
completed IRS Form W-8BEN.
Complete only if applicable:
I am not a U.S. citizen or other U. S. person. I am a citizen of ______________________________________________
(attach a completed IRS Form W-8BEN). Country
FATCA reporting does not apply.
Certification instructions: You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not
apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an IRA, and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct
TIN/SSN.
SECTION 5. AGREEMENT. (Read completely before signing.)
The undersigned understand and agree that the Company is requested and authorized to take the action specified on this form. Any
request is subject to the conditions and provisions of the policy and the current rules and practices of the Company. For the change
requested, it is expressly represented and warranted that no other person, firm or corporation has any interest in said policy except the
undersigned and that no proceedings in insolvency or bankruptcy have been instituted or are pending against the undersigned.
SECTION 6. SIGNATURES.
Any person who knowingly presents a false statement to an insurance company may be guilty of a criminal offense and may be subject to
penalties under state law.
Counterparts - This Agreement may be executed in counterparts, each of which shall be deemed to be an original, but all of which, taken
together, shall constitute one and the same agreement.
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications
required to avoid backup withholding in Section 4.
Owner’s Signature Date
Signature ___________________________________________________________________________________
If the owner is an entity, provide business/trust/organization name and officer/trustee’s title below.
Name of Business/Trust/Organization (if applicable) __________________________________________________
Officer/Trustee’s Title (if applicable) _______________________________________________________________

Assignee’s or Irrevocable Beneficiary’s Signature (if any) Date
Signature ___________________________________________________________________________________
Title of Person Signing on behalf of Assignee (if applicable) ____________________________________________
L-78 (I) Page 2 of 2 Stock No. 25132 Rev. 5/15

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AMERICAN FAMILY LIFE INSURANCE COMPANY

POLICY SURRENDER IN FULL – ALL LIFE INSURANCE POLICIES

Primary Insured’s Name (first) (mi) (last) (suffix)

City State Zip

L-78 (I) Page 1 of 2 Stock No. 25132 Rev. 5/15

Name of Business/Trust/Organization (if applicable) __________________________________________________

Officer/Trustee’s Title (if applicable) _______________________________________________________________

Title of Person Signing on behalf of Assignee (if applicable) ____________________________________________

L-78 (I) Page 2 of 2 Stock No. 25132 Rev. 5/15

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