Form 05897-30 - Request For Service - Colonial Life & Accident Insurance Company
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1
2Colonial life & accident Insurance Company
Request foR seRvice:
What type of service are you requesting? Please check only the boxes that apply.
1
General InformatIon
Insured’s name as currently listed on the policy:
Social Security Number (SSN):
Date of Birth(mm/dd/yyyy):
List all policy numbers related to this request (required to process):
Employer Name:
2
name ChanGe
( Please attach a copy of legal evidence )
Previous Name:
Current Name:
Reason: Correction Marriage/Divorce Other
3
address ChanGe
Address:
Apt. #:
City:
State:
ZIP:
Telephone: (
)
Mobile: (
)
Email:
4
request for ChanGe of BenefICIary fo
rm
Please visit us at our website or contact us at 1.800.325.4368 to request a copy of the Change of Beneficiary form.
5
PremIum Payment method ChanGe
( YOU HAVE A CHOICE OF THREE EASY PAYMENT METHODS.) Please select one.
1. Please deduct monthly premiums from my
2. Please bill me directly.
3. Change to Payroll Deductions.
banking account.
Choose one of the following:
Employer Name:
RANGE: A). 1st-5th B). 6th-10th C). 11th-15th D). 16th-20th
Quarterly
(Submit a payment
_______________________________
E). 21st-26th. Your draft will occur on one of the dates
3 times your monthly premium.)
oR
oR
within the range you have selected.
Billing Control Number or Account Number:
Semi-annually
(Submit a payment
Please attach a voided check and circle one range of days you would
6 times your monthly premium.)
_______________________________
like your checking account to be drafted.
Annually
(Submit a payment
Signature of checking account owner:
Please contact your Plan Administrator to start payroll
12 times your monthly premium.)
deduction.
_________________________________________
6
CanCellatIon, surrender or PolICy ChanGe
( You must also complete sections 9 and 12 on the reverse side.)
Cancel/surrender the policy(s) [
This option will cancel or cash surrender your policy. ]
Cancel the following riders on the policy(s):
Spouse Rider
Dependent Rider (This will cancel coverage for ALL dependents)
[
This option will cancel policy riders only. ]
Other (name rider) ______________________________________________
Change Two-Parent to Individual
Change Two-Parent to One-Parent
Change One-Parent to Individual
Please provide name, birthdate, &
Name:
Date of Birth:
SSN:
social security number for spouse/
Name:
Date of Birth:
SSN:
dependent(s) continuation:
7
PolICy loan
(You must complete sections 9 and 12 on the reverse side. (Select either Policy Loan or Withdrawal (Section 8, not both)
I am requesting a policy loan for the following amount: $______________________
If the amount requested is more than
Please selection
the available cash value, we will
I am requesting a policy loan for the maximum amount available.
one option.
process this request for the maximum
amount available.
I am also requesting information regarding repayment of my loan on my Universal Life policy.
By signing on the reverse side, I hereby assign the policy to the insurer as collateral.
Policy loans are available on select life policies only. Minimum loan amounts may apply as stated in your policy contract. You will receive annual loan and interest
notices until the loan is fully repaid. For information regarding repayment of your loan, please contact us at 1.800.325.4368.
Continued on Reverse Side ➡
11/12
05897-30
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