Prudential Life Insurance Cash Surrender Forms Details

The Prudential surrender form is a document that policyholders can use to terminate their life insurance policy. The form must be completed and submitted to the insurance company in order to initiate the termination process. In this article, we will provide an overview of the Prudential surrender form and guide you through the steps involved in terminating your policy. We highly recommend that you speak with an insurance professional before making any decisions regarding your life insurance policy. Terminating a policy can have serious financial consequences, so it is important to understand all of your options before taking any action.

Listed below are some details about prudential surrender form. Before you decide to fill in the form, it is worth studying a little more about it.

QuestionAnswer
Form NamePrudential Surrender Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesthe prudential insurance company of america cash surrender request, prudential life insurance cash surrender forms, prudential surrender form, cash surrender form prudential

Form Preview Example

The Prudential Insurance Company of America – GUL/GVUL

P.O. Box 8769

Philadelphia, PA 19176-8769

Paid-up Surrender Request

Please print using blue or black ink.

Instructions Use this form to surrender your paid-up coverage. Please follow these steps:

1.Read each section before completing this form.

2.Complete sections 1 through 4. Please print using blue or black ink.

3.Sign and date your request in section 5.

4.If your certiicate has been assigned, the assignee (new owner) or trustee must complete all sections of this form.

5.Return the completed form to Prudential at the address above. You may fax it to 800-764-1469.

Call our Group Universal Life Customer Service Center toll-free at 800-562-9874 with any questions, Monday to Friday, 8:00 a.m.–8:00 p.m. Eastern time.

 

 

 

On this form you, your, and I refer to the individual requesting to end coverage.

 

 

 

 

 

 

 

Important

This information will help you complete sections 3 and 4, which are required by the Internal Revenue Service.

 

 

Tax

Please read it carefully. Prudential and its representatives cannot give tax or legal advice. Prudential generally

 

Information

must report to its certiicate owners all payments of taxable income on Internal Revenue Form 1099. These

 

 

 

payments include the surrender proceeds from a life insurance certiicate to the extent a taxable gain is

 

 

 

distributed. The surrender proceeds include all amounts distributed from the certiicate, including any loans

 

 

 

that are paid off by certiicate values at the time of the surrender. You may wish to consult your tax or legal

 

 

 

adviser for more information.

 

 

 

 

Tax

 

 

 

 

Federal and state income tax withholding. Federal and some state tax laws require us to withhold income

 

Withholding

taxes from the taxable portion of a cash surrender. By signing and dating this form and making no entries to

 

Election

section 3, you can elect not to have any taxes (federal or state) withheld, but you will still be liable for payment

 

 

 

of any taxes due. Please check the appropriate boxes if you want to have federal and/or state income taxes

 

 

 

withheld. If you request a check to be mailed to a non-U.S. address, you cannot elect out of withholding.

 

 

 

Note: Some states require state withholding when federal withholding is elected or required.

 

 

 

Estimated tax and possible penalties. If you elect to have no income tax withheld from your surrender

 

 

 

payment or if you do not have enough income tax withheld, you may be responsible for payment of estimated

 

 

 

tax. You may incur penalties if your withholding and estimated tax payments are not suficient. You may be

 

 

 

subject to IRS penalties if you fail to provide your correct Taxpayer Identiication Number, fail to report taxable

 

 

 

interest or dividends on your tax return, or give false tax information. You may be subject to a 10 percent federal

 

 

 

1

2

 

 

 

 

 

income tax penalty if you are under the age of 59 ⁄ and your certiicate is classiied as a modiied endowment

 

 

 

contract (MEC).

 

 

 

 

 

 

 

 

 

Tax

Citizenship. You must indicate if you are not a U.S. citizen or resident alien. In that case, you must state the

 

Certification

country of which you are a citizen and submit an applicable IRS Form W-8 (BEN, BEN-E, ECI, EXP, IMY). In most

 

 

 

instances Form W-8BEN will be the appropriate form.

 

 

 

Backup withholding. You must tell us if the IRS has notiied you that you are subject to backup withholding

 

 

 

because you did not report all your taxable interest and dividends on your tax return. You are not subject to

 

 

 

backup withholding if either (a) you did not receive such a notice from the IRS, (b) the IRS recently told you

 

 

 

that you are no longer subject to a backup withholding order, or (c) you are exempt from such withholding.

Taxpayer Identification Number and date of birth. You must include your Taxpayer Identiication Number (TIN) and date of birth. The TIN for the certiicate is:

Your Social Security Number if you are an individual or the owner of a sole proprietorship;

The Employer Identiication Number (EIN) if you represent a trust, estate, corporation, partnership, or tax-exempt organization;

The TIN of the grantor/trustee or that of the actual owner of a trust-like entity not recognized as a legal or valid trust under state law.

FATCA Reporting. You must tell us if you are subject to FATCA reporting.

GL.2002.104 Ed. 10/2015

Page 1 of 3

About Cash Surrenders

Before ending coverage or surrendering your certificate, you should understand the effects of such transactions.

Once you surrender the certiicate, the life insurance coverage ends and all rights, privileges, or beneits under the certiicate end.

You will lose the valuable death beneit that would otherwise be paid to your beneiciary and the favorable tax treatment of the death beneit.

We will make the surrender payment to the owner or owners of the certiicate unless otherwise instructed. If the certiicate has been assigned, we will pay any cash values withdrawn or surrendered to the owner(s) or assignee.

Your request will be void only if it is withdrawn, in writing, before the check is issued or the transaction is processed.

You may incur a taxable gain.

If your certiicate is classiied as a MEC you may be subject to less favorable tax treatment, possibly including a 10 percent federal income tax penalty.

1

 

Insured’s

First Name of Insured

 

 

 

 

 

 

 

 

MI

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Apt.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

State

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daytime Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has insurance been assigned?

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(If Yes, the assignee must complete all sections of this form and submit a copy of the assignment.)

 

 

 

 

 

 

Insured’s Employer/Association

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Group Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

Assignee’s

 

First Name of Assignee

 

 

 

 

 

 

 

 

MI

 

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Estate or Trust

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Apt.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

State

 

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daytime Telephone Number

 

 

 

 

 

 

 

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

month

 

day

 

year

 

3Tax Withholding Election

If you would like taxes withheld, complete this section. Otherwise, we will not withhold taxes unless required by law.

Withhold federal income taxes from the taxable portion of the payment. Withhold state income taxes from the taxable portion of the payment.

GL.2002.104 Ed. 10/2015

Page 2 of 3

 

Return this page to Prudential

4

Taxpayer

Identification

Number

Certification

First Name of Employee or Assignee MI

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check One:

 

I am a U.S. person

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(including a resident alien)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I am a citizen of

Attach completed applicable Form W-8 (BEN, BEN-E, EXP, ECI, IMY)

Under penalties of perjury, I certify that:

My Taxpayer Identiication Number is

(For individuals, the Taxpayer Identification Number is the Social Security Number.)

Under penalties of perjury, I certify that the number shown on this form is my correct Tax Identiication Number (Social Security Number). I am not subject to backup withholding because (a) I have not been notiied by the Internal Revenue Service (IRS) that I am subject to backup withholding, (b) the IRS has told me that I am no longer subject to a backup withholding order or (c) I am exempt from backup withholding. I am not subject to FATCA reporting.

Check here only if the following apply to you:

I have been notiied by the Internal Revenue Service that I am subject to backup withholding due to under reporting of interest or dividends.

I am subject to FATCA reporting.

X

Employee/Assignee Signature

month day

year

5Signature(s) I elect to surrender my paid-up insurance under the Group Universal Life certiicate. I understand this transaction will be processed in accordance with the group contract, as outlined in the Group Universal Life Booklet-Certiicate. I have read and understand the cash surrender information. A check will be issued within 14 days after the request has been processed.

Please make a photocopy of this form for your records.

X

Certificate Owner’s or Assignee’s Signature and Date

month day

year

Group Universal Life (Contract Series: 83500 and 96945) and Group Variable Universal Life (Contract Series: 89759) are issued by The Prudential Insurance Company of America, a Prudential Financial company, 751 Broad Street, Newark, NJ 07102 and offered through Prudential Investment Management Services LLC, a registered broker/dealer, 655 Broad Street, 19th Fl. Newark, NJ 07102. Prudential Investment Management Services LLC is a Prudential company. Please refer to the Booklet-Certiicate, which is made a part of the Group Contract, for all plan details, including any exclusions, limitations and restrictions which may apply. If there is a discrepancy between this document and the Booklet-Certiicate/Group Contract issued by Prudential, the terms of the Group Contract will govern. Contract provisions may vary by state. Contract series: 83500 and 96945.

© 2016 Prudential Financial, Inc. and its related entities.

Prudential, the Prudential logo, and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide.

GL.2002.104 Ed. 10/2015

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