If you have a Mass Mutual life insurance policy, then you may be wondering what to do if you decide to surrender it. It's important to understand the process for surrendering a policy so that you can make the best decision for yourself and your family. The Mass Mutual Policy Surrender Form is a document that outlines the steps involved in surrendering a life insurance policy. In this article, we'll provide an overview of the information contained in the form, so that you can better understand what to expect if you choose to surrender your policy.
Listed here, you will discover quite a few details about mass mutual policy surrender PDF. Our recommendation is that you look at this material before you decide to start working with the form.
| Question | Answer |
|---|---|
| Form Name | Mass Mutual Policy Surrender |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | mass mutual whole life surrender form, form to surrender life insurance policy for mass mutual, massmutual annuity full surrender request, massmutual change of agent form |
Massachusetts Mutual Life Insurance Company and affiliates, Springfield MA
www.massmutual.com
Request to Pay Dividends, Surrender Additional Benefits Rider or Flexible Term Rider, or Change Dividend Option
Not for use with Qualified Plan or
Keogh (H.R. 10) Plan owned policies
1
Policy Information
Policy Number(s): |
_________________________________________________________ |
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Insured(s) Name(s): |
_________________________________________________________ |
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Owner(s) Name(s): |
_________________________________________________________ |
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Owner’s address: |
PO Box, Apt #, Street: |
_____________________________________ |
Check here if this is a new address |
City, State ZIP: |
_____________________________________ |
Owner’s daytime phone number: _________________________________________________________
Owner’s email address: _________________________________________________________
2
Withdraw or Apply Dividends
Withdraw dividends from: |
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Maximum Amount |
or Specified Amount |
Withdraw Accumulated Dividends |
$___________________ |
Surrender Dividend Additions |
$___________________ |
Surrender Additional Benefit Rider for net cash of |
$____________________ |
Surrender Flexible Term Rider |
A partial surrender is not allowed |
In conjunction with the above withdrawal surrender, pay or apply dividends as follows:
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$_______________ |
To Premium |
On Policy _________________________ |
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$_______________ |
To Loan Principal |
On Policy_________________________ |
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$_______________ |
To Loan Interest |
On Policy _________________________ |
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Automatic Premium Loan (APL) any balance due for premium and/or loan interest. |
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To a Loan Payoff* |
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On Policy _________________________ |
*The loan payoff will be determined as of the date this form is received at our Home Office, in good order. |
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WARNING: |
If any portion of the payment is taxable, an IRS Form 1099 (if required) will be issued to the |
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owner of this policy regardless of whether surrender/withdrawal proceeds are payable to a |
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third party. Any additional tax reporting required to be made to a third party is the responsibility of the owner.
Page 1 of 4
Return this page to MassMutual
F6367 1211
Policy Number(s): ___________________________
Name(s) of Insured(s): _______________________
Request to Pay Dividends, Surrender Additional Benefits Rider or Flexible Term Rider, or Change Dividend Option
Not for use with Qualified Plan or Keogh (H.R. 10) Plans owned policies
3
Changes
Cancel Additional Benefits Rider premium as of the current paid to date (to be used in conjunction with the above surrender, and only in those instances where premiums for the Additional Benefits Rider are still being paid).
Cancel the
Change the Dividend Option to:
Pay dividends in cash
Apply dividend to premium (this option is not available for policies that are paid monthly)
Accumulate dividends at interest
Purchase
Cancel the Modified Payment Option (MPO)
4
Withholding Election and Required Notice
The distributions you receive from this policy are subject to Federal Income Tax withholding unless you elect not to have withholding apply. Withholding will apply only to the portion of your distribution that is includable in your income. If you elect no withholding or if you do not have enough withheld, you may be responsible for payment of estimated tax, and you may incur penalties if your withholding and estimated tax payments are not sufficient. If no election is made, any applicable taxes will be withheld. If taxes are withheld, receipt of your payment may be delayed by the calculations required.
NOTE! If you elect Federal Income Tax withholding, you are also electing State Income Tax withholding if applicable under relevant State law.
I have read the above notice regarding Federal Income Tax withholding and:
I do not want Federal Income Tax withheld from my payment.
I want Federal Income Tax withheld from my payment.
MEC WARNING: If your policy has been designated a Modified Endowment Contract (MEC), and you are under age 59 ½, any taxable gain may be subject to a 10% tax penalty. Please consult your tax advisor.
5Payee/Mailing Address
This section must be completed if the proceeds are to be made payable to and mailed to someone other than the policy owner at the address of record. Notary Public stamp may
apply, see Page2. .Exception: proceeds will only be payable to the trust itself on a
Payee Name: |
___________________________ |
Payee Address: |
___________________________ |
Payee Address: |
___________________________ |
City, State, Zip: |
___________________________ |
Distributions may not be sent to an agent/broker address.
6Delivery Options
Checks are mailed through the U.S. Postal Service First Class Mail unless otherwise requested.
U.S Postal Service - Mail (No charge – please allow 10 business days for normal delivery)
UPS Priority (The carrier charges a fee and cannot ship to a P.O. Box. Please provide the information requested below. If not provided, your surrender check will be mailed through the regular U.S. Postal Service.)
UPS Account Name__________________________
UPS Account Number ________________________
Zip Code associated with account # ____________
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F6367 1211 |
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Return this page to MassMutual |
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Request to Pay Dividends, Surrender |
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Policy Number(s): _____________________________ |
Additional Benefits Rider or Flexible |
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Term Rider, or Change Dividend Option |
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Name(s) of Insured(s): _________________________
Not for use with Qualified Plan or Keogh (H.R. 10) Plans owned policies
7 Owner Tax ID Required Please enter your TAX ID (SSN or EIN as applicable)
Check one:
SSN
EIN
Under penalties of perjury, I certify that the above is my correct Taxpayer Identification Number, and I am a U.S. person (U.S. citizen or resident alien), and the Internal Revenue Service (IRS) has NOT notified me that I am subject to backup withholding. The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.
8Individual, Joint or Multiple Owners Signature Section (All owners must sign.)
______________________________ |
_____________________________________________________ |
_______________ |
Printed Name of Owner |
Signature of Owner |
Date Signed |
______________________________ |
_____________________________________________________ |
_______________ |
Printed Name of Additional Owner |
Signature of Additional Owner |
Date Signed |
______________________________ |
_____________________________________________________ |
_______________ |
Printed Name of Additional Owner |
Signature of Additional Owner |
Date Signed |
9Corporate, Partnership or Trust Owned Signature Section
________________________________________________________________________________ |
________________ |
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Printed Name of Corporation, Partnership or Trust |
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Date of Trust |
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I am the sole officer of the corporation listed |
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____________________________________ |
__________________________________ |
___________ |
________________ |
Printed Name of Corporate Officer or Trustee |
Signature of Corporate Officer or Trustee |
Title |
Date Signed |
____________________________________ |
__________________________________ |
____________ |
________________ |
Printed Name of Corporate Officer or Trustee |
Signature of Corporate Office or Trustee |
Title |
Date Signed |
10 |
Assignee Signature Section |
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______________________________ |
_____________________________________________ |
________________ |
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Printed Name of Assignee |
Signature & Title |
Date Signed |
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______________________________ |
_____________________________________________ |
________________ |
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Printed Name of Additional Assignee |
Signature & Title |
Date Signed |
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11 |
Notary Public Stamp (if applicable) |
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A Notary Public stamp is required for distributions greater than $50,000 only if in conjunction with one of the following:
•Checks are made payable to someone other than the policy owner, or
•Proceeds are sent to an address other than the address of record, or
•Proceeds are sent to an address that has been changed in the past 30 days A Notary Public stamp can be obtained from most banks or credit unions.
Subscribed and sworn to before me this ______________________ day of _______________________________
______________________________________________________________________________________________
Signature of Notary Public (Official stamp/seal required) |
My commission expires |
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12 Signature Instructions
The following descriptions explain the signature requirements for each type of ownership arrangement.
Corporation, partnership, |
Include the full name of the corporation. Print or type the full name and corporate title of each |
limited partnership |
officer who signs. If the officer is the insured or a family member, we require the signature of |
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another officer who is not related or, if all officers are related, the signature of two officers. If |
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the insured is the only officer, we require one of the following: check the box titled Sole |
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Officer in the signature section or a letter on company stationary to that effect or the |
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insured’s signature with the corporate seal affixed. EXAMPLE - John Doe, |
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President/Partner/General Partner, ABC Corporation |
Trust ** |
Those trustees required to sign under the trust agreement. Include the full name of the trust, |
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the date of the trust agreement and the title(s) of the officer(s), if corporate trust, signing. |
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EXAMPLE – Mary Smith as Trustee under the ABC Trust Agreement dated mm/dd/yyyy |
Custodian |
• In all states except South Carolina and Vermont, include the full name of the |
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custodian “as custodian for (insert name of minor) under the (name of state)’s |
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UTMA.” EXAMPLE |
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UTMA. |
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• In South Carolina and Vermont, include the name of the custodian “as custodian for |
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(insert name of minor) under the (name of state)’s UGMA.” EXAMPLE |
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as custodian for Alice Doe under the Vermont UGMA. |
Executor** |
Include the full name of the appointed executor, administrator, or personal representative, as |
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“executor, administrator, or personal representative (list only one capacity) for the estate of |
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(insert name of deceased), deceased.” If not previously submitted, a copy of the death |
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certificate is required. EXAMPLE – Joan Doe, executor for the estate of Sam Doe, |
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deceased. |
Legal Guardian |
Include the full name of the legal guardian/conservator, “as guardian/conservator of the |
/Conservator** |
estate of (insert name of person affected).” EXAMPLE – Joan Doe as Guardian/Conservator |
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of the Estate of Sam Doe. |
Include the full name of the |
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of Attorney) |
person).”EXAMPLE – Joan Doe, |
If the policy is assigned |
The owner and assignee must sign. Include the full name of the assignee. If the assignee is |
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a corporation, also include the title(s) of all officer(s) signing. NOTE: If the right being |
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exercised is granted to the assignee, only the assignee’s signature is required. |
** Copies of the legal document that established authority must be submitted with this form unless already on file.
13 Customer Service Information
Once you have reviewed and completed this form, please return pages
Mail to: |
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MassMutual Financial Group |
MassMutual Customer Service Center: |
Internet Service |
Enterprise Document Management Hub |
Connection: |
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1295 State Street |
Monday through Friday, 8 a.m. – 8 p.m. |
www.massmutual.com |
Springfield MA |
Eastern Time |
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Fax to: |
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Attention Life Hub |
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Retain this page for your records |
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F6367 1211