Plan Change Forms


The following forms are available to print and either mail or fax to our office.

Bank Draft and Credit/Debit Card Authorization
Authorize electronic debit entries to your checking or savings account or from your credit or debit card for your premiums.  If you are starting this service or changing banks you should complete this form.

Policy Changes
Use this form to make changes in your policy such as change of policy owner, beneficiaries, or name.

Assign the benefits of the policy to a third party, mostly to funeral homes.

Release of Assignment
Used by the assignee to acknowledge the release of their assignment on a policy and removing their ability to claim benefits.

Cancellation Request
Cancel a policy you currently own.

Policy Reinstatement Request – this is used to reinstate a policy that has lapsed. We can only reinstate policies up to 9 months from the date the policy lapsed. Click on the link below that correspond to your policy form number:
For application forms L-222, L-222D, Term 5R
For application form L-222A
For application form L-222J
For application form Term
For application form L-222B
For application form JT25

Annuity Withdrawal
Complete this form if you want to withdraw funds from your Annuity Plan 2000 policy.

Annuity Roll Over
Complete this form if you want to transfer funds to the annuity account from another annuity account you have with another company and continue to defer your taxes.

Death Claim
This form is used by beneficiaries to claim the proceeds of a policy after a death has occurred.

Affidavit of Lost Policy
Complete and submit this form with your claim if you lost your original policy.

Assignee Acknowledgment
This form is required in all cases in which the policy benefits are assigned.

Release of Medical Records
This form is used to allow us to received medical records of the insured, in case it is needed for underwriting or claim processing.

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