An AXA Financial Company PO 4763 Syracuse, NY 13221-2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Owner’s Information section. Ensure you provide your Policy Number(s) and the Insured’s Name accurately. If there is an address change, check the corresponding box.
3. Select the Type of Request you are making—Policy Loan, Disbursement of Dividends, or Surrender. Complete the relevant sections based on your selection.
4. For a Policy Loan request, indicate whether you want a check issued or if you prefer maximum loan options. Fill in any required amounts.
5. If applying for Disbursement of Dividends, specify how you would like to apply dividends and complete any necessary financial details.
6. In the Delivery Options section, choose how you want your payment sent—via First Class Mail, Express Delivery, or Wire Transfer—and provide any required banking information if applicable.
7. Complete the Tax Withholding section by providing your Social Security Number and indicating your preferences for federal income tax withholding.
8. Finally, ensure all signatures are completed in the Signatures section before submitting your form for processing.

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