Request For Policy Service Form
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1
2Request for
Policy Service
Check company which issued policy:
Transamerica Life Insurance Company
Monumental Life Insurance Company
1. Policy Owner and Insured Information
Policy Owner
Policy Owner Name
(Last, First, M.I.)
Social Security No.
Insured
Insured Name
(Last, First, M.I.)
Social Security No.
Policy No.
Employer Name
SD No.
2. Name Changes
Change name of
Insured
Owner
Payor
Beneficiary
From
To
Reason for Change
Marriage***
Divorce
Correction
Other
3. Policy Owner Changes
Record the following Transfer of Ownership**
Change Owner Address
New Owner Name
Social Security No.
Address
Daytime Phone No.
Evening Phone No.
All right, title and interest in this policy are transferred to the new owner. This transfer is subject to any policy loans and collateral assignments. The
change of ownership does not change the beneficiary. Any existing owner’s designee or contingent owner is revoked.
4. Billing Changes
New Premium Mode
Pre-Authorized checking
Direct Bill
New Premium Frequency
Monthly
Quarterly
After Tax
Other
Change Planned Periodic Payment To
$
5. Reduction In Benefits
Reduce face amount to
$
(may be subject to company imposed surrender penalties)
Change Planned Periodic Premium for reduced face amount (see #4)
Cancel Accidental Death Rider
Cancel Waiver Provision
Cancel Children’s Term Rider
Other
6. Beneficiary Changes
I hereby revoke any and all prior beneficiary designations and existing settlement agreements, if any, and elect to change the beneficiary(ies) under the
above numbered policy as follows:
Primary Beneficiary(ies): For multiple beneficiaries, payment will be made in equal shares unless otherwise noted below.
Full Name (as it should
appear on company records)
%
Street Address
City/State/Zip
Relationship
Date of Birth
Contingent Beneficiary(ies): Receives proceeds only if all Primary Beneficiaries predecease the Insured. For multiple beneficiaries, payment will be
made in equal shares unless otherwise noted.
Full Name (as it should
appear on company records)
%
Street Address
City/State/Zip
Relationship
Date of Birth
It is understood and agreed that, unless otherwise directed, proceeds will be paid in accordance with the policy provisions.
TWM-PolSvc-120108
Page 1 of 2
**Spouse or equivalent, as defined by governing state law. ***Marriage or equivalent, as defined by governing state law.
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Parent category: Business