Policyholder'S Change And Service Request Form
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2Policyholder’s Change and Service Request
For American Heritage Life Insurance Company (Home Office: Jacksonville, FL)
Notice to Policyholder: Funds released when borrowing, surrendering, or withdrawing any policy values
may affect the guaranteed elements, non-guaranteed elements, face amount or surrender value of the policy.
Policy Number (use separate form per policy)
Name of Insured (Last, First, Middle)
Agent Name and Number (Please Print)
Take the following action(s) regarding this policy subject to AHL’s current rules.
Change from Family to Individual coverage on health policy due to ________________________.
1.
Policy Changes,
If due to death of Insured, Name of New Insured _______________________________________,
Reductions or
SS#, _____________________________________ Date of Birth _________________________.
Removals
Add Newborn child (if no underwriting required)
Name of Newborn _______________________________________________________________.
Date of Birth of Newborn _______________________________.
Reduce the amount of insurance
From
To
Basic Policy
___________________________
_____________________
_______________________
___________________________
_____________________
Remove the following Benefit Rider _________________________________________________
Change Death Benefit Option from 2 to 1
(if changing from 1 to 2, application must be submitted for underwriting purposes)
Cancel Life policy when replacement policy is issued (for life policies with no fund value)
$_________________________________ or the maximum allowed by policy, if less.
2.
Annuity or UL Partial
*Under UL Policy, the death and fund value will be reduced by the amount of partial surrender.
Surrender
(Withdrawal)
*Service Fees or surrender charges will be deducted from fund value.
Note: Form C-123 also required with this request.
$_________________________________ in cash.
3.
Policy Loan
For maximum amount available.
To pay current premium due on policy number(s) _______________________________________
Other __________________________________________________________________________
Automatic Premium Loan. Make the Automatic Premium Loan Provision:
Operative
Inoperative
This loan plus any other debt owed AHL is a first lien against the policy values.
There are no proceedings in bankruptcy pending against any owner signing this form.
$_________________________________ in cash.
4.
Dividend Withdrawal
For maximum amount available.
To pay current premium due on policy number(s) _______________________________________
To apply to loan on policy number ___________________________________________________
Other __________________________________________________________________________
I elect option number ___________________ as stated in my contract.
5.
Maturity Request
Payments to be made
Monthly
Quarterly
Semi-Annually
Annually
If applicable, payments to be made for a period of _______________ Years.
Change Maturity Date to _____________________________________.
Change Maturity Age to _____________________________________.
Note: If requesting a maturity option, for C-123 also required.
Place policy in non-billing status
6.
Flexible Premium
Place policy back into a premium paying status.
Payment Changes
(FPA
Change premium to $_____________________________________________________________.
or UL only)
(Per
Week
Month
Semi-Annual
Annual)
Make change effective ____________________________________________________________.
Insured
Owner
Payor
7.
Change Name of
From ____________________________________ To _________________________________
Reason for change _______________________________
(Complete change of Address Form if needed.)
Note: If the reason for the change of name is other than marriage, a certified copy of the court order is required.
Name (Last, First, Middle)
Other Policy Numbers to be changed
8.
Address Change
Street
City
State
Zip
B-092-1
(Signatures on Next Page)
(10/06)
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