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POLSURRENDER (05/20)
U.S. Retail Life Operations
Full Policy Surrender Request
Use this form to request a full surrender and termination of your life insurance policy(ies).
Metropolitan Life Insurance Company
Metropolitan Tower Life Insurance Company
Things to Know Before You Begin
Social Security or Tax ID number is required in Section 2.
All policy owners must sign and date the form in Section 5.
Complete and return pages 1-4 of
this form to avoid processing delays
82608873-c3bc-4233-
b43f-051adaf7195d
SECTION 1: About Your Policy (All policies listed below must have the same policy owner(s))
Policy Number
Insured First Name Middle Name Last Name
Policy Number
Insured First Name Middle Name Last Name
Policy Number
Insured First Name Middle Name Last Name
Policy Number
Insured First Name Middle Name Last Name
SECTION 2: About the Owner (Choose one and complete appropriate sub-section):
Individual (or individuals, if the policy is co-owned)
Owner - First Name Middle Name Last Name
Social Security Number Phone Number E-Mail Address
Co-Owner - First Name Middle Name Last Name
Social Security Number
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POLSURRENDER (05/20)
A Trust, Charity, or Business Entity
Print Full Name of Trust/Charity/Business Entity
Date of Trust (mm/dd/yyyy) Tax ID Number of Trust/Charity/Business Entity
Contact Person - First Name Middle Name Last Name
Phone Number E-Mail Address
SECTION 3: Full Surrender, Termination and Payment
I request a full surrender and termination of the life insurance policy(ies) listed in Section 1 and request
payment of the proceeds as indicated below.
Payment Options: Please select one of the following payment methods
Receive a check
Open a new Total Control Account
®
(TCA) or deposit into my existing TCA #
Please see the Additional information page for features of the Total Control Account (TCA) to help you make an
informed decision. The decision whether or not to select a check or the TCA as a payment method is entirely
yours. The features listed are merely general factual information about the TCA and do not constitute a
recommendation or advice on the payment method you should select.
If you choose to receive a check, please let us know where we should mail it.
Street Address City State ZIP
Should we use this address for all future correspondence with you?
Yes No
Special Instructions:
Florida Residents Only:
Check this box: If your insurance agent recommended (advised) you to surrender your life insurance policy
and the surrender proceeds will NOT be used to fund or purchase another life insurance policy or annuity
contract.
The state of Florida requires that we first provide you with important disclosure information.
We are unable to send your surrender proceeds via EFT or wire. We will promptly send you a check.
Include your email address or fax number in the space provided below so we can send the important
disclosure information to you.
E-Mail Address Fax Number
SECTION 4: About Income Tax Withholding
Under current federal income tax law, we are required to withhold 10% of the taxable portion of the cash
surrender value and pay it to the IRS unless you tell us in writing not to withhold tax. Some states also require
us to withhold state income tax if we withhold federal tax.
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POLSURRENDER (05/20)
You are responsible for paying income tax on the taxable portion of your payment, even if we do not withhold
taxes. In making your decision about withholding taxes, you should consider that penalties under the estimated
income tax rules may apply if your withholding and estimated income tax payments are not sufficient.
Check here if you do not want us to withhold federal and state income tax.
(This choice is void if we do not have your Social Security number or Tax ID number or if you reside
outside the U.S.)
SECTION 5: Certification and Signature
Under the penalties of perjury I certify:
1. The number shown on this form is my correct taxpayer identification number, and;
2.
I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been
notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to
report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and;
(If you have been notified by the IRS that you are currently subject to backup withholding because of under
reporting interest or dividends on your tax return, you must cross out and initial this item.)
3. I am a U.S. citizen or other U.S. person, and;
4.
I am not subject to FATCA reporting because I am a U.S. person and the account is located within the United States.
(If you are not a U.S. citizen or other U.S. person for tax purposes, please cross out the last two certifications
and complete appropriate IRS documentation, e.g. IRS Form W-8BEN for individuals, which can be found on
the IRS website).
The Internal Revenue Service does not require your consent to any provision of this document other
than the certifications required to avoid backup withholding.
All Policy owner(s) must sign and date option A or B.
If there are more than two Owners, each additional Owner must sign, date, and provide their name and
social security number on a separate page and submit with this form.
For an individual acting on behalf of the Owner, the full name of the Owner's fiduciary or agent and
supporting legal documentation is required.
Option A: Individual Owner Signature(s)
Signature of Owner
Date (mm/dd/yyyy)
Title (if acting in a representative capacity)
Print - First Name Middle Name Last Name
Signature of Co-Owner (If applicable) Date (mm/dd/yyyy)
Title (if acting in a representative capacity)
Print - First Name Middle Name Last Name
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POLSURRENDER (05/20)
Option B: Trust/Business Entity Owner Signature(s)
Before signing, see signature requirements on page 5
Signature of Authorized Person Title Date (mm/dd/yyyy)
Print - First Name Middle Name Last Name
Signature of Authorized Person Title Date (mm/dd/yyyy)
Print - First Name Middle Name Last Name
SECTION 6: Collateral Assignee and/or Irrevocable Beneficiary Signature(s)
All Collateral Assignee(s) must sign and date this form.
Any Irrevocable Beneficiary must also sign and date this form.
Before signing, see signature requirements on page 5
Signature of Authorized Person Title Date (mm/dd/yyyy)
Print - First name Middle Name Last Name
Signature of Authorized Person Title Date (mm/dd/yyyy)
Print - First Name Middle Name Last Name
For Sales Office Use Only
Sales Office/Agency Number – Representative ID Date (mm/dd/yyyy)
Print Sales Representative
First Name Middle Name Last Name
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POLSURRENDER (05/20)
SECTION 7: Additional Information and Instructions
About the Total Control Account
Total Control Account (TCA) - Please keep this page for your records.
If payment is made by establishing a new TCA, the signature you provide will be placed on file with that account.
Availability:
A TCA may be elected when the amount payable to you is at least $10,000, or you have an existing TCA
Account issued by the same MetLife affiliated insurance company that issued the policy (you must provide the
TCA account number). The TCA generally is not available to corporate entities, or to residents of foreign
countries. For more information, call our Customer service center at 1-800-638-7283.
Features:
Interest compounded daily. Rates are set weekly and are equal to or higher than one of two nationally
recognized money market rate indexes. Interest is credited monthly and is currently taxable.
Detailed, easy-to-read statements.
Free unlimited check writing privileges - Minimum check amount $250.
No penalties for withdrawing all or part of your money.
No charge for processing or printing checks. Free check reorders.
No transaction or monthly fees, although there may be charges for stop orders and special services.
Additional amounts from other sources may not be added to the TCA, nor can amounts withdrawn be
redeposited. However, proceeds from other life insurance policies and annuity contracts issued by the same
insurer may be added to an existing TCA in some circumstances.
Information available electronically
through MetLife's eSERVICE web site.
Principal and interest are guaranteed by the financial strength and claims paying ability of the affiliated
MetLife insurance company which issued the policy/policies above.
Signature Requirements
Owner Type Signature Requirement
Partnership owned LLP
Signature and title of one general partner other than the insured (not a limited partner).
Sole proprietorship Signature of Owner, followed by the title “Sole Owner”.
Corporate/Charity
Signature and title of one authorized officer (other than the insured).
Most common authorized officers include:
CFO, President, Vice President, Treasurer, Corporate Secretary, Principal(LLC),
Managing Member (LLC), or Loan Officer (on behalf of collateral assignee)
Trust
Signature of all required Trustees, followed by the title “Trustee.”
Please submit a copy of the Trust Certification with this form.
SECTION 8: How to Submit This Form
Retain a copy of this completed form for your records.
Return pages 1-4 of this form to the appropriate address or fax number listed below. Please note that there
may be printing on both sides of each page. We cannot process your request unless we receive all 4 pages.
Life Policies
For Variable Life Policies
Mail:
Metlife
P.O. Box 336
Warwick, RI 02887-0336
Metlife
P.O. Box 358
Warwick, RI 02887-0358
Fax:
401-827-2225
Email:
INDLifeRequests@metlife.com
We’re Here to Help
You can reach us at 1-800-638-5000. Our customer service center is open Monday through
Friday, 8:00 a.m. to 6:00 p.m., Eastern time.
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