Expiration Date: 1 31 2025-2026

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Click ‘Get Form’ to open it in the editor.
Begin by entering your First, Middle, and Last Name in the designated field. Ensure accuracy as this information is crucial for identification.
Fill in your Insurance File Number and Mailing Address. This ensures that all correspondence reaches you without delay.
Provide your Policy Number and Daytime Telephone Number. This helps in verifying your policy details quickly.
Select the appropriate box under 'I HEREBY SURRENDER MY' to indicate which insurance policy you are surrendering.
Complete the Future Dividend Option section by choosing how you want dividends applied or paid out.
Sign and date the form at the bottom, ensuring that you do not print but sign in ink for authenticity.
Lastly, provide payment information if opting for direct deposit, ensuring all details are accurate to avoid delays.

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