Lafayette Life Insurance Company Policy Service Forms

Here are several forms commonly used to service Bank on Yourself policies.
Fill out all forms and attach any requested additional paperwork. You may email your forms to teresa@livingwealthyfinancial.com or fax to 512-597-1908.
If you have any questions, do not hesitate to call our offices at 1-800-382-0830.
As always, thank you for your business!

Pre-Authorized Withdrawal Form
This form can be used to set up electronic monthly drafts from your checking or savings account to your Bank on Yourself policy. You may choose to direct funds to your premium, paid-up additions rider (LPUA), premium deposit fund, or towards an outstanding loan.
Be sure to include a voided check when returning this form to our office.

Electronic Funds Transfer
This form is used when requesting an electronic funds transfer from Lafayette Life Insurance Company to your checking or savings account.
Be sure to include a voided check when returning this form to our office.

Change of Beneficiary
This form is used to add or remove beneficiaries from your Bank on Yourself policy.
Include all beneficiaries each time you make a change.
***Please note that page 2 is only to be used for trusts.***

Payment Remittance Form
For premiums, LPUA contributions, or payments you would like to apply to outstanding loans, you will use the bottom portion of this form.
Include your policy number and name. Be sure to indicate how you would like the funds applied in the Memo box.
Teresa’s agent number is 50650 for clients in Texas, and 50649 for clients in all other states.

Policy Service Form
To use this form to request a policy loan:
1.) Fill out the policy number, insured’s name, and owner’s name (if different than insured).
2.) In section 4- indicate whether you would like to request to take the maximum policy loan or a specific amount.
3.) Choose whether you would like to have LLIC mail a check to you, or direct deposit funds into your checking account. If you would like a direct deposit, check “Special Instructions” and write, “Authorization for EFT attached”. You will also fill out and return the Electronic Funds Transfer if you choose direct deposit.
4.) On page 2, under Withholding Election check “DO NOT Withhold Federal Income Tax”. Policy loans are not a taxable event.
5.) Be sure to date, sign, and fill in your address and social security number. You will also be required to have another party sign as a witness to your signature and include their address. (Spouses may act as a witness)

To use this form to make a change to a loan repayment:
You can add a monthly loan repayment or increase/decrease the amount of an existing loan repayment. All loans are grouped together into one outstanding loan amount LLIC will continue to withdraw the loan payment until the loan balance is zero, or until you make a change to the draft.
(***Note: Only available for clients who have set up a monthly premium draft***)
1.) Fill out the policy number, insured’s name, and owner’s name (if different than insured).
2.) In section 4, check the box next to “Preauthorized Loan Repayment”
3.) Fill in the new loan repayment amount
4.) On page 2, be sure to date, sign, and fill in your address and social security number. You will also be required to have another party sign as a witness to your signature and include their address. (Spouses may act as a witness)

To use this form to change your address:
1.) Fill out the policy number, insured’s name, and owner’s name (if different than insured).
2.) Under section 1, check the box next to “Change of Address”, and indicate whether the change is for the insured, beneficiary, owner, or payor of the policy.
3.) Write the old and new addresses on the lines provided.
4.) On page 2, be sure to date, sign, and fill in your address and social security number. You will also be required to have another party sign as a witness to your signature and include their address. (Spouses may act as a witness)