SURRENDER REQUEST FORM - unifiedlife.com

SURRENDER REQUEST form Policy Number: _____ Insured: _____ _____ (First Name) (Last Name) The undersigned owner of the referenced policy hereby forwards the policy to and requests that the policy be canceled and the cash SURRENDER value of the policy, if any, be paid to the owner. The owner and any irrevocable beneficiary hereby indicate his/her understanding that the cancellation of the policy and withdrawal of the cash SURRENDER value terminates the insurance coverage provided under the policy as of the effective date of the SURRENDER , which is the date all requirements are received by the company.

Form W-9 (Rev. 12-2014) Page . 2 Note. If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially

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