Policy Cancellation Request
Date:
Please cancel the following GBU Life insurance policies/annuity contracts:
Applicant: Policy Number:
Applicant: Policy Number:
Applicant: Policy Number:
This request is submitted by (check all that apply):
Applicant
Policy Owner Agent
The effective date of the above life insurance policy/annuity contract cancellation(s) requested, with all coverages (implied and stated), shall be discontinued as of the date the request is received by GBU Financial Life. As of the request effective date, GBU will no longer draft premiums and/or will refund all premiums paid in conjunction with the placement of this policy.
PLEASE NOTE THAT AFTER GBU IS IN RECEIPT OF THIS REQUEST, THERE IS NO LIFE INSURANCE/ANNUITY BENEFIT IN FORCE FOR ALL POLICIES INDICATED ABOVE.
Signatures:
Applicant
Date (mm/dd/yyyy)
Agent
Policy Owner (if different than applicant)
Date (mm/dd/yyyy)
Date (mm/dd/yyyy)