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Frequently Used Forms

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Frequently Used Forms

Click the buttons below to access some of the most frequently used forms by our policyholders. Contact us with any questions.

Policyholder Forms

Multi Purpose Change Form

Use this form to update your beneficiaries, request a loan and make a number of other policy changes. Return this form using the contact information at the bottom of the form.

Download Multi Purpose Form

Bank Authorization for Payment (PAC) Form

Want to have your premiums drafted from your bank account automatically each month? 

Complete this form and return it to us.

Download PAC Form

Loan Coupons

Print these coupons, complete the information and send the coupon in along with your loan payment.

Download Loan Coupons

Form FAQs

General Information

  1. Not all options listed on the Request for Service form may be available at all or at this time. 
  2. If we have your signature on file, please have someone other than the beneficiary sign as a witness. If we do not, or your signature has changed, a notary will be required. A notarized signature is always required to surrender a policy .
  3. If you are only changing your name, the form does not need to be completed, simply send in supporting documentation (marriage license, divorce decree, court order, driver’s license, etc.)

  1. The current owner must complete Section 2 of the Policyowner Request for Service Form.
  2. The bottom of this form must be signed by both the current and the new owners.
  3. If the policy was purchased in a community property state (AZ, CA, ID, LA, NM, NV, TX, WA, or WI) the owner’s spouse must sign the form or it must be noted you do not have a spouse or spouse is deceased.
  4. All ownership change requests MUST BE notarized and contain the notary stamp or seal.
  5. A completed and signed W-9 form must be sent with the Policyowner Request for Service Form.

Contact our office so that we can review the policy and provide you with the requirements, contact us..

  1. Complete Section 3 of the Policyowner Request for Service Form.
  2. The bottom of this form must be signed by the owner.
  3. If the policy was purchased in a community property state (AZ, CA, ID, LA, NM, NV, TX, WA, or WI) the owner’s spouse must sign the form or it must be noted you do not have a spouse or spouse is deceased.
  4. If we have your signature on file, please have someone other than the beneficiary sign as a witness. If we do not, or your signature has changed, a notary will be required.
Important information:
  • At least one primary beneficiary must be named.
  • A funeral home cannot be a beneficiary.
  • If multiple primary or contingent beneficiaries are listed and they are intended to receive uneven distribution of the proceeds, please indicate this by indicating percentages, not dollar amounts.
  • Make sure to include ALL beneficiaries, submitting this form revokes all previous named beneficiaries.
  • If the beneficiary being named is a trust, include the signature page of the trust agreement.

If a power of attorney is appointed for a policy owner, we must receive a copy of the power of attorney documents (all pages) to review and approve. A POA document does not always give the power to make changes to the policy. This will be dependent on the language in the POA. Power of Attorney for healthcare or Guardianship of the Person will not be approved for handling insurance transactions.

In order to surrender the policy the owner must follow these steps:
  1. Complete Section 21 of the Policyowner Request for Service Form.
  2. It is important to complete the tax withholding portion of this form. If it is not completed and there is taxable income, 10% of the taxable income will be withheld, unless another percentage is mandatory as noted in Section 21 on the form.
  3. The original policy must be returned, or Section 6 must be completed by checking the box for NO ACTION REQUESTED.
  4. The bottom of this form must be signed by the owner and notarized. The notary stamp or seal must be visible.
  5. If the policy was purchased in a community property state (AZ, CA, ID, LA, NM, NV, TX, WA, or WI) the owner’s spouse must sign the form or it must be noted you do not have a spouse or spouse is deceased.

The face amount may be decreased as low as the minimum allowed for this product ($25,000.00). This will usually result in a decrease in premium. Please complete section 11 of the Request for Service form.

  • Your policy must be paid within the 30 day grace period.
  • Complete section 19 of the Policyowner Request for Service Form. The amount available is determined by current cash value and outstanding loans. Please contact our office for a loan quote.
  • The interest rate will be 8%.

Extended Term Insurance. Please complete Section 13 of the Policyowner Request for Service Form.

Reduce Paid Up Insurance. Please complete Section 14 of the Policyowner Request for Service Form.

You may change your default option by completing section 7 of the Policyowner Request for Service Form.

If your policy lapses, you may be able to reinstate it to its original value. You will need to send in any back premiums and may be asked to fill out an application. Please contact our office and we will review your policy for reinstatement.

  1. Please complete the Bank Authorization for Premium Payment and include a voided check.
  2. Your policy must be paid current for us to set you up on a bank draft. If you are behind, please indicate that you would like us to draft multiple premiums or include additional premiums.
  3. If you would like to add or change a loan repayment, please complete section 20 on the Request for Service form.
  4. If you would like to change your premium mode, please complete section 15 on the Request for Service form.