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Run: Policyholder Dividend Application Election Form

Use this Policyholder Dividend Application Election Form to record how a declared dividend should be handled, from cash payment to premium reduction or accum...

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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. (required)

Yes No N/A

I consent to the insurer using the information provided on this form to process my dividend election and maintain an audit trail. (required)

Yes No N/A

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 (required)

Policyholder Name (required)

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? (required)

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. (required)

Yes No N/A

Signature

Signature may be required depending on policy terms and insurer procedures.

Submission Date

Automatically recorded for audit trail purposes.

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Email (required)

Your name (optional)

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