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REQUEST FOR FULL SURRENDER I (we) hereby elect

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SVC-110-PL Request for Full Surrender (Must return ALL pages) – page 1 of 3 08/2015
Policy Number: __________________
Policy:
Non-Tax Qualified Tax Qualified
Insured:
Owner(s):
REQUEST FOR FULL SURRENDER
I (we) hereby elect to surrender this policy for its cash surrender value, if any. The date used for calculation of
policy values shall be the policy’s monthly anniversary following the Company’s receipt of the cancellation
request. I (we) hereby release and discharge said Company from any and all liability whatsoever under this policy
as of the date of this request. Please attach policy.
I (we) hereby certify that no proceedings in bankruptcy or insolvency, voluntary or involuntary, have ever been
instituted by or against me (us), that I (we) am (are) of legal age, am (are) not under guardianship or other legal
disability and that said Policy is not assigned or pledged to any other person or corporation other than the
assignee signed below, and that I (we) will indemnify and save harmless the said Company from any other and
further claim thereunder.
Please choose your method of payment below.
Check by mail
All checks will be made payable to the owner(s). If the policy has more than one owner, the
disbursement will be split equally among all owners and will be mailed to each owner at the address
we have on record for that owner. If requested, we will issue one check in all owners name if located
at the same address.
Check will be made payable to: __________________________________________________________
__________________________________________________________
Electronic Fund Transfer (EFT): Direct Deposit is limited to $100,000.
If you would like to have the proceeds directly deposited to the owner's checking account; please attach a
voided check to this surrender form. Counter or beginner checks are not acceptable.
Protective Life Insurance Company
Life and Health Insurance Administration
P.O. Box 12687
Birmingham, AL 35202-6687
SVC-110-PL Request for Full Surrender (Must return ALL pages) – page 2 of 3 08/2015
Policy Number: __________________
REQUEST FOR FULL SURRENDER
Notice of Withholding
The taxable portion of distributions you receive from the above policy are subject to Federal income tax
withholding and state income tax withholding, where applicable, unless you elect not to have withholding apply.
If you elect not to have withholding apply to your distribution, you may be responsible for payment of estimated
tax. You may incur penalties under the estimated tax rules if your withholding and estimated tax payments are
not sufficient.
If you do not indicate your intent below, we will withhold Federal Income Tax and State Income Tax, where
applicable, from the taxable portion of your distribution.
I have read the above information and I DO NOT want to have Federal income tax (and state
income tax, where applicable) withheld from my distribution.
I have read the above information and I DO want to have Federal income tax (and state
income tax, where applicable) withheld from my distribution.
MICHIGAN: residents, please refer to the attached MI W-4P form for tax withholding or opt out information or
visit www.michigan.gov/taxes.
NORTH CAROLINA: resident, please refer to the attached NC-4P form for tax withholding or opt out information
or visit www.dor.state.nc.us.
SVC-110-PL Request for Full Surrender (Must return ALL pages) – page 3 of 3 08/2015
Policy Number: __________________
SIGN HERE FOR THE ABOVE REQUEST(S)
Please read the Signature Requirements to avoid a delay in processing.
Owner’s Email Address
Owner’s Signature
Owner’s Daytime Phone Number
Owner's Social Security Number/Tax ID
Owner’s Email Address
Owner’s Signature
Owner’s Daytime Phone Number
Owner's Social Security Number/Tax ID
Owner’s Email Address
Owner’s Signature
Owner’s Daytime Phone Number
Owner's Social Security Number/Tax ID
Witness Signature
Disinterested Party of Legal Age
Witness - Print Name
Assignee Signature
(Provide title if officer of corporation)
Assignee - Print Name
Signature Requirements
1. Please complete the forms in BLACK ink to ensure that all signatures are legible and return ALL pages.
2. If the Policy is assigned, the Assignee must also sign or complete a release of assignment form.
3. If the Owner resides in a Community Property State, we recommend that the Owner's spouse join in signing
this form. This is for the protection of both parties. Please indicate your status as spouse or owner on the
above signature line.
4. If the Policy is owned by a partnership, association or company, this form should be signed by an officer other
than the Insured. If the policy is owned by a corporation, this form must be signed by an officer other than
insured and the signature must be attested by the Secretary of the corporation or two officers should sign.
The title of the officer should be included.
5. Signatures should be witnessed by a disinterested party of legal age.
6. A notarized signature is required by the owner(s) to mail a check to an address other than the address of
record.
7. If the policy has multiple owners, all owners’ signatures are required. A notarized signature is required by
each owner if requesting to make the check payable to owner(s) other than as indicated in the “Check will be
made payable to” section.
8. If policy is trust owned, please send the section of the trust that indicates the title of the trust, trustees rights,
any pages pertaining to the Life Insurance policy and the signature page. ALL applicable trustees must sign.
9. If the POA, Legal Guardian or anyone with legal authority is signing this form, please send “ALL” pages of the
document. All applicable signatures are required.
10. The completed “Taxpayer Identification Number and Certification” form is required from each owner for this
distribution.
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REQUEST FOR FULL SURRENDER I (we) hereby elect

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Completed 17 November 2021

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