Mass Mutual Policy Surrender – Fill Out and Use This PDF

Policy Number(s):

_________________________________________________________

Insured(s) Name(s):

_________________________________________________________

Owner(s) Name(s):

_________________________________________________________

Owner’s address:

PO Box, Apt #, Street:

_____________________________________

Check here if this is a new address

City, State ZIP:

_____________________________________

Withdraw dividends from:

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

$_______________

To Premium

On Policy _________________________

$_______________

To Loan Principal

On Policy_________________________

$_______________

To Loan Interest

On Policy _________________________

Automatic Premium Loan (APL) any balance due for premium and/or loan interest.

To a Loan Payoff*

On Policy _________________________

*The loan payoff will be determined as of the date this form is received at our Home Office, in good order.

WARNING:

If any portion of the payment is taxable, an IRS Form 1099 (if required) will be issued to the

owner of this policy regardless of whether surrender/withdrawal proceeds are payable to a

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F6367 1211

Return this page to MassMutual

Request to Pay Dividends, Surrender

Policy Number(s): _____________________________

Additional Benefits Rider or Flexible

Term Rider, or Change Dividend Option

______________________________

_____________________________________________________

_______________

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

________________________________________________________________________________

________________

Printed Name of Corporation, Partnership or Trust

Date of Trust

I am the sole officer of the corporation listed

____________________________________

__________________________________

___________

________________

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

______________________________

_____________________________________________

________________

Printed Name of Assignee

Signature & Title

Date Signed

______________________________

_____________________________________________

________________

Printed Name of Additional Assignee

Signature & Title

Date Signed

11

Notary Public Stamp (if applicable)

Signature of Notary Public (Official stamp/seal required)

My commission expires

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

another officer who is not related or, if all officers are related, the signature of two officers. If

the insured is the only officer, we require one of the following: check the box titled Sole

Officer in the signature section or a letter on company stationary to that effect or the

insured’s signature with the corporate seal affixed. EXAMPLE - John Doe,

President/Partner/General Partner, ABC Corporation

Trust **

Those trustees required to sign under the trust agreement. Include the full name of the trust,

the date of the trust agreement and the title(s) of the officer(s), if corporate trust, signing.

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

custodian “as custodian for (insert name of minor) under the (name of state)’s

UTMA.” EXAMPLE –Joan Doe as custodian for Alice Doe under the Massachusetts

UTMA.

• In South Carolina and Vermont, include the name of the custodian “as custodian for

(insert name of minor) under the (name of state)’s UGMA.” EXAMPLE –Joan Doe

as custodian for Alice Doe under the Vermont UGMA.

Executor**

Include the full name of the appointed executor, administrator, or personal representative, as

“executor, administrator, or personal representative (list only one capacity) for the estate of

(insert name of deceased), deceased.” If not previously submitted, a copy of the death

certificate is required. EXAMPLE – Joan Doe, executor for the estate of Sam Doe,

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

of the Estate of Sam Doe.

Attorney-in-Fact** (Power

Include the full name of the attorney-in-fact as “Attorney-in-Fact for (insert name of

of Attorney)

person).”EXAMPLE – Joan Doe, Attorney-in-Fact for Sam Doe.

If the policy is assigned

The owner and assignee must sign. Include the full name of the assignee. If the assignee is

a corporation, also include the title(s) of all officer(s) signing. NOTE: If the right being

exercised is granted to the assignee, only the assignee’s signature is required.

Mail to:

MassMutual Financial Group

MassMutual Customer Service Center:

Internet Service

Enterprise Document Management Hub

1-800-272-2216

Connection:

1295 State Street

Monday through Friday, 8 a.m. – 8 p.m.

www.massmutual.com

Springfield MA 01111-0001

Eastern Time

Fax to:

Attention Life Hub

1-866-329-4527

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