Mass Mutual Policy Surrender PDF Details

The Mass Mutual Policy Surrender form is a crucial document for policyholders who are considering altering their life insurance coverage with Massachusetts Mutual Life Insurance Company and its affiliates. Located in Springfield, MA, this company provides a straightforward way for policyholders to request several types of changes. These include the withdrawal or application of dividends, surrender of additional benefits or flexible term riders, and alteration of dividend options. Importantly, this form is not applicable to policies owned under Qualified Plans or Keogh (H.R. 10) Plans. It captures essential details such as policy information, withdrawal preferences, election of withholding for tax purposes, and specifies the payee and mailing address for the distribution of proceeds. Additionally, the form details delivery options and requires tax identification from the owner along with signatures from all involved parties, demonstrating the form's comprehensive nature in facilitating significant policy changes. A warning is also provided regarding taxable amounts and potential IRS implications. With sections tailored to individual, joint, corporate, and trust ownerships, plus a specific segment for assignees and the necessity for a Notary Public stamp under certain conditions, this form caters to a wide array of policyholder needs while ensuring legal compliance and accuracy in processing.

QuestionAnswer
Form NameMass Mutual Policy Surrender
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesmass mutual whole life surrender form, massmutual whole life full surrender form, massmutual life insurance surrender form, mass mutual cash surrender form

Form Preview Example

Massachusetts Mutual Life Insurance Company and affiliates, Springfield MA 01111-0001

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):

_________________________________________________________

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:

_____________________________________

Owner’s daytime phone number: _________________________________________________________

Owner’s email address: _________________________________________________________

2

Withdraw or Apply Dividends

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

In conjunction with the above withdrawal surrender, pay or apply dividends as follows:

 

$_______________

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

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 one-year term agreement as of the next policy anniversary

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 paid-up additions – future dividends (this option is not available on Term policies)

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 trust-owned policy.

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 # ____________

Page 2 of 4

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

 

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

________________________________________________________________________________

________________

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)

 

 

 

 

 

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

Page 3 of 4

Return this page to MassMutual

F6367 1211

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

 

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.

** 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 1-3 for processing. To submit your request, please mail or fax this to:

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

 

 

 

Page 4 of 4

 

 

Retain this page for your records

 

F6367 1211

How to Edit Mass Mutual Policy Surrender Online for Free

Having the purpose of making it as quick to apply as it can be, we made our PDF editor. The entire process of filling the mass mutual cash surrender form can be straightforward in case you keep to the following actions.

Step 1: Choose the "Get Form Here" button.

Step 2: Now you are on the form editing page. You may edit, add content, highlight certain words or phrases, put crosses or checks, and put images.

Create the mass mutual cash surrender form PDF by typing in the text needed for each individual section.

portion of fields in mass mutual whole life surrender form

In the To Premium On Policy, To Loan Principal On Policy, To Loan Interest On Policy, Automatic Premium Loan APL any, To a Loan Payoff, On Policy, The loan payoff will be determined, WARNING, If any portion of the payment is, and Page of Return this page to field, write down the information you have.

mass mutual whole life surrender form To Premium On Policy, To Loan Principal On Policy, To Loan Interest On Policy, Automatic Premium Loan APL any, To a Loan Payoff, On Policy, The loan payoff will be determined, WARNING, If any portion of the payment is, and Page of Return this page to blanks to insert

The software will request data to easily submit the section Policy Numbers, Names of Insureds, Changes, Request to Pay Dividends Surrender, Cancel Additional Benefits Rider, Cancel the oneyear term agreement, Change the Dividend Option to, Pay dividends in cash, Apply dividend to premium this, Accumulate dividends at interest, Purchase paidup additions future, and Cancel the Modified Payment Option.

stage 3 to entering details in mass mutual whole life surrender form

Please be sure to describe the rights and responsibilities of the sides inside the I have read the above notice, I do not want Federal Income Tax, I want Federal Income Tax withheld, MEC WARNING If your policy has, PayeeMailing Address, This section must be completed if, Payee Name, Payee Address, Payee Address, City State Zip, Distributions may not be sent to, Delivery Options, Checks are mailed through the US, Class Mail unless otherwise, and business days for normal delivery section.

Entering details in mass mutual whole life surrender form step 4

End by reviewing all of these sections and filling out the relevant particulars: Policy Numbers, Names of Insureds, Request to Pay Dividends Surrender, Owner Tax ID Required Please, Check one, SSN, EIN, Under penalties of perjury I, Individual Joint or Multiple, Printed Name of Owner, Signature of Owner, Date Signed, Printed Name of Additional Owner, Signature of Additional Owner, and Date Signed.

Filling in mass mutual whole life surrender form stage 5

Step 3: When you have selected the Done button, your file is going to be accessible for export to any kind of device or email address you specify.

Step 4: Make copies of the form - it may help you refrain from upcoming challenges. And don't be concerned - we don't disclose or check your data.

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