Transcription of Request for Full or Partial Surrender Form
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Example: bachelor of science
Request for Full or Partial Surrender Form
AF9605Q (08/20) Page 1 of 3 Administrative Office: PO Box 410288, Kansas City, MO 64141-0288 Phone: Fax: Email: Policyowner s Name Policy Number Policyowner s Street Address (Include City, State, and ZIP) Email Address Daytime Phone Number Reason for Surrender (Required for 403b plans) Please select only one reason. 59 Separation From Service Disability Financial Hardship Withdrawal: Also complete the 403B Financial Hardship form (Page 3). Request for 10% Penalty Free Partial Surrender /Transfer (Annuity and 457 Plans Only) Request for Partial Surrender /Transfer $_____ (Specify Amount Requested) Process Net Amount Specified Above or Process Gross Amount Specified Above (If not specified, net amount will be processed)
NOTE: The release of policy values may affect the guaranteed elements, non -guaranteed elements, face amount, or surrender value of the policy from which the values are released. The policy owner(s) has the right to receive information regarding the existing policy or contract values
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