Policyholder Dividend Application Election Form

Captures how a declared policyholder dividend should be applied, such as cash payment, premium reduction, or accumulation with the insurer.

Submission Notice

• I understand this form records my dividend application election and will be used to process the declared dividend according to my policy terms.
• I consent to the insurer using the information provided on this form to process my dividend election and maintain an audit trail.
• What happens after I submit?
  Your election will be reviewed and applied to the declared dividend for the applicable policy period. If additional information is needed, the insurer may contact you using the details provided.

Policyholder and Policy Details

• Policy Number
• Policyholder Name
• Email Address
  Optional. Used only if we need to confirm your election or request clarification.
• Policy Effective Date
  Optional if needed to distinguish between multiple active policies.

Dividend Election

• How should your dividend be applied?
• Preferred cash payment method
• Accumulation instructions
  Optional instructions for how accumulated dividends should be handled, if permitted by your policy.

Certification and Submission

• I certify that I am authorized to make this election for the policy listed above and that the information provided is accurate.
• Signature
  Signature may be required depending on policy terms and insurer procedures.
• Submission Date
  Automatically recorded for audit trail purposes.