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| Question | Answer |
|---|---|
| Form Name | Fl Cs Form |
| Form Length | 6 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 30 sec |
| Other names | lost policy release forms, loss policy release form fillable, loss policy release, lost policy form |
LOST POLICY/CONTRACT STATEMENT AND REQUEST FOR DUPLICATE
Western Reserve Life Assurance Co. of Ohio |
4333 Edgewood Rd. NE, Cedar Rapids, IA 52499 |
Transamerica Life Insurance Company |
CURRENT POLICY/CONTRACT INFORMATION
POLICY/CONTRACT NUMBER __________________________________ OWNER _______________________________________________
OWNER ADDRESS_____________________________________________ OWNER PHONE NUMBER _______________________________
INSURED/ANNUITANT ________________________________________ JOINT OWNER (IF ANY) __________________________________
INSTRUCTIONS TO POLICY/CONTRACT OWNERS
1.If you have lost your Policy/Contract, please review and complete Section I: Lost Policy/Contract Statement.
2.If you are also requesting a Duplicate Policy/Contract, please also review and complete Section II: Request for Duplicate Policy/Contract and enclose the $25.00 fee.
Section I: Lost Policy/Contract Statement
The undersigned does hereby certify that the above Policy/Contract has been lost or destroyed under the following circumstances and that no person(s), partnership, corporation or other entity has any claim or interest in said Policy/Contract or its benefits by virtue of any gift, sale, assignment, pledge, property settlement, divorce, or other court action.
IN CONSIDERATION of the Company granting this request without the surrender of said original Policy/Contract, the undersigned hereby promises and agrees to indemnify and hold harmless the Company from any and all losses or injuries which it may incur as a result
of granting this request. It is further agreed that if the original Policy/Contract is found it will be returned to the Administrative Office of the Company. This indemnification shall be binding upon the undersigned’s heirs, executors, administrators, successors, and assigns.
_________________________________________________________________________________________________________________
Please Print Name
_________________________________________________________________________________________________________________
Signature of Policy/Contract Owner |
Date |
Section II: Request for Duplicate or Certificate of Insurance/Annuity
NOTE: A $25 fee must accompany any request for a complete duplicate policy or contract. In lieu of a duplicate policy, a Certificate ofInsurance will be issued at no charge.
Based on the foregoing statements, the undersigned requests that the Company issue a duplicate Policy/Contract or Certificate of Life Insurance/Annuity, or grant the benefits under said Policy/Contract that have been requested without requiring the surrender of said original Policy/Contract.
IN CONSIDERATION of the Company granting this request without the surrender of said original Policy/Contract, the undersigned hereby promises and agrees to indemnify and hold harmless the Company from any and all losses or injuries which it may incur as a result
of granting this request. It is further agreed that if the original Policy/Contract is found it will be returned to the Administrative Office of the Company. This indemnification shall be binding upon the undersigned’s heirs, executors, administrators, successors, and assigns.
_________________________________________________________________________________________________________________
Please Print Name
_________________________________________________________________________________________________________________
Signature of Policy/Contract Owner |
Date |
|
|
PS00521 – 11/08 |