Notice To Owner Regarding Replacement Of Life Insurance Page 2
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7Notice to Owner Regarding
Replacement of Life Insurance
Form D14-1180
(To be used when the existing and proposed policies are written
by the same company.)
M M a a s s s s a a c c h h u u s s e e t t t t s s M M u u t t u u a a l l L L i i f f e e I I n n s s u u r r a a n n c c e e C C o o m m p p a a n n y y
C C . . M M . . L L i i f f e e I I n n s s u u r r a a n n c c e e C C o o m m p p a a n n y y
M M M M L L B B a a y y S S t t a a t t e e L L i i f f e e I I n n s s u u r r a a n n c c e e C C o o m m p p a a n n y y
1 1 2 2 9 9 5 5 S S t t a a t t e e S S t t r r e e e e t t S S p p r r i i n n g g f f i i e e l l d d M M A A 0 0 1 1 1 1 1 1 1 1 - - 0 0 0 0 0 0 1 1
4 4 1 1 3 3 - - 7 7 8 8 8 8 - - 8 8 4 4 1 1 1 1
MUST BE PRESENTED TO, SIGNED AND DATED BY THE OWNER AND PRODUCER AT THE TIME OF APPLICATION
PLEASE READ CAREFULLY. This information has been prepared for you so that you may make an informed decision on the use of any of your
policy values to fund the purchase of a new policy. Please see the reverse side of this form for explanatory notes and instructions as to
how this form has been completed.
Part A – Current Policy Information
Life
Annuity
Policyowner Name: ______________________________________ Policy Number: _________________________________________
Current Death Benefit: $ _____________________ Premium Amount: $ ___________________ Mode of Payment ________________
Cash Surrender Value: $ _____________________ Paid-up Addition Value: $ _______________ Dividend Value: $ ________________
(The BENEFIT and VALUES stated above will be reduced as funds are used to purchase the policy proposed in Part B, below.)
Part B – Proposed Policy Information
Life
Annuity
Initial Death Benefit: $ _____________________ Proposed Premium Amount: $ ____________ Mode of Payment ________________
Proposed Effective date: _____________________ Premium payable to age _____________ or for ___________ years.
NOTE: If you are replacing your current policy, or using 25% or more of your policy values, you may request a WRITTEN comparison between
your current policy and the proposed policy. The comparison is to illustrate the policy values for both policies.
Part C – Source of Funding for the Proposed Policy
A loan in the amount of $ _________________ will be taken from the value of your CURRENT POLICY each _____________ (mode), bear-
ing a current loan interest of _________ %.
A partial surrender in the amount of $ _________________ will be taken from the value of your CURRENT POLICY each _____________
(mode).
A dividend withdrawal in the amount of $ _________________ will be taken from the value of your CURRENT POLICY each
_____________ (mode).
Part D – Your Current Policy Could Terminate
If the policy values of your CURRENT POLICY are used as a source of funding for the purchase of an additional policy, it is estimated that
your CURRENT POLICY will terminate on ___________ (date).
It is estimated that you will begin making premium payments for the PROPOSED POLICY from your own funds on ___________ (date) in the
amount of $ ___________ to be paid each ___________ (mode).
NOTE: Since the values and premiums stated on this from may change over time, the estimated date upon which you will need to begin making
payments from your own funds for the PROPOSED POLICY may also change. Estimates as to dates when policies will terminate or when payments
must begin assume the continuation of current (or guaranteed) factors, and such calculations are based upon the assumption that any
premiums or interest due on loans are paid when due.
Signatures
x
__________________________________________________________________________
________________________________
Date
Signature of Owner
x
__________________________________________________________________________
________________________________
Signature of Producer or Company Officer
Date
__________________________________________________________________________
Florida Licensed Producer ID No. or Corporate Title
(See reverse side for instructions)
(A signed and dated copy of this notice must accompany the application.)
F5436FL REV. 807
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