Loan Request Repayment Form PDF Details

Do you need to request repayment of a loan from a borrower? Whether it is an installment payment or a lump sum, ensuring that funds are collected in an organized and structured manner is vital for any successful loan management system. This blog post will discuss the essential elements of creating an effective loan request repayment form. From identifying important contact information to understanding legal requirements, we’ll cover everything needed to create a fool-proof document for tracking loan amounts owed by your borrowers. Stay tuned as we walk through this crucial tool for maintaining accurate records and protecting both lender and borrower!

Form NameLoan Request Repayment Form
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesAssignee, YR, forms, Repayment

Form Preview Example

Monumental Life Insurance Company

Transamerica Life Insurance Company Western Reserve Life Assurance Co. of Ohio Administrative Office located at:

4333 Edgewood Road N.E., Cedar Rapids, IA 52499-0001

FAX 800-235-4782

Loan Request/Repayment

Policy/certificate number (s)___________________________



Phone Number_____________________________

Fill out all required information in sections 1 and 2 and sign below.

1.Loan Request

Select one:

_____A cash loan for $ ___________________ (In addition to present loan, if any).

_____A cash loan of accumulated interest only (Limited to single premium universal life).

_____A cash loan for the largest amount available.

_____A loan to pay premiums on policy # __________________, due date ______/______/ _____.


_____Add the Automatic Premium Loan (APL) option to my policy.

2.Loan Repayment

Increase the amount I am billed each regular period (monthly, quarterly, etc.) by $________________

(Minimum $10.00)

Insured /Annuitant____________________________________



Date Signed

Social Security Number

Date of Birth




Date Signed

Social Security Number

Date of Birth


Signature Title Date Signed


Signature- (if none, indicate, NONE)

32913 0908