Notice To Owner Regarding Replacement Of Life Insurance Page 3
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7P P o o l l i i c c y y D D i i s s c c l l o o s s u u r r e e F F o o r r m m
C
OMPLETE ONE FORM FOR EACH PREVIOUSLY ISSUED POLICY
A
NY REQUIRED REPLACEMENT AND SALES FORMS MUST ALSO BE COMPLETED
O
NE COPY IS DELIVERED TO THE POLICYOWNER AND ONE COPY MAINTAINED BY THE INSURED
Any and all information applicable to the transaction shall be fully and completely disclosed on Form D14-1180. If the information requested
does not apply to the transaction, the words “not applicable” or “N/A” shall be entered.
PART A
The information to be disclosed in Part A of Form D14-1180 shall apply to the current, in-force policy for which policy values are being utilized
as a source of funding for the purchase of additional insurance contract(s). For purposes of this form, “current death benefit” is defined as
the sum of the death benefit payable under the base policy, all life insurance riders covering the principal insured (other than special
contingency death riders), paid-up additional insurance and dividends, minus outstanding indebtedness. The term “cash surrender value” is
defined as the cash value of the policy or contract net of any outstanding indebtedness and surrender charges, and less any dividend value.
The term “paid-up addition value” is defined as the cash value of additional insurance purchased with policy dividends. The term “dividend
value” is defined as the total cash value of all policy dividend left on deposit with the company to accumulate at interest.
PART B
The information to be disclosed in Part B of Form D14-1180 shall apply to the proposed additional insurance contract(s) being funded by policy
values in a current, in-force policy. For purposes of this form, “proposed premium amount” is defined as any recurring payment which is
planned to be paid or which is required to be paid under the proposed policy.
PART C
The information to be disclosed in Part C of Form D14-1180 shall apply to the current, in-force policy, and shall indicate the manner in which
the policy values are being used to fund the purchase of the proposed policy. Part C is not to be completed if the current policy is totally
surrendered. However, in the event of a total surrender of the current policy, Parts A, B, D, and the signature block of this form must still be
completed.
When completing Part C of this form, each and every source of funding for the proposed policy must be identified, i.e., whether a policy loan,
partial surrender, or dividend withdrawal or any combination thereof is being utilized. If more than one source of funding will be utilized to
fund the initial and/or future premiums for the proposed policy, all applicable sections of Part C shall be completed.
For purposes of this form, a “partial surrender” is defined as any amount taken from the value of the current policy which is less than the
total cash value available under such policy. The term “mode” is defined as the frequency upon which a policy loan, partial surrender or
dividend withdrawal will be taken from the value of the current policy. In the event of a single loan, surrender or withdrawal, the words “one
time only” shall be entered in the space provided. The term “loan interest rate” is defined as the rate of interest in effect on the date that this
form is completed, as specified in the current policy contract.
PART D
The information to be disclosed in Part D of Form D14-1180 shall apply to the current, in-force policy and the proposed additional policy,
respectively.
SIGNATURES
In order to evidence that the required disclosure has been made, Form D14-1180 shall be signed and dated by the soliciting agent or by a
Corporate Officer, as well as by the policyowner. For identification purposes, the agent or Corporate Officer shall enter his or her Florida
License Number or Corporate title, respectively, in the space provided.
F5436FL REV. 807
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