Regular withdrawal request form

Only use this form if:

You want to start, stop or change a regular withdrawal
Your policy allows the kind of withdrawal you’re requesting
You’re based in the UK
You have a UK bank account in your name(s) that the money can be paid into
You’re the policyholder

Do not use this form if:

You want to take a one-off amount of money, or cash in the whole of your policy
You’re a pension customer, or an FMISA customer
You live outside of the UK
You don’t have a UK bank account in your name to pay the money into
The policy is held in trust, or has been assigned to someone that isn’t the policyholder
Your policy includes a feature called ‘natural income’ or ‘bonus linked withdrawals’

If you’re not sure whether this form is suitable for you, please call us.
Important: withdrawals of more than 5% a year of the amount paid into this policy could lead to a higher rate tax charge in the year of withdrawal. You should consider whether this affects you and the request you’re making and if you need to you should seek independent advice or guidance.

We need this information so that we can make payment. You can find out more about how we use personal information by viewing our full privacy notice.

If this policy is jointly owned then the form must be completed by both owners.

Policy number

Is this policy jointly owned?

Yes

No

Your name

Your date of birth

Your national insurance number

Your daytime telephone number

Your email address

Your residential address

Second policyholder's name

Second policyholder's date of birth

Second policyholder's national insurance number

Second policyholder's daytime telephone number

Second policyholder's email address

Second policyholder's residential address

What you like to do?

Start a new regular withdrawal

Change an existing regular withdrawal

Stop an existing regular withdrawal

Bank name

Account holder name

Account number

Sort code

Share account number (building society accounts only)

What day of the month would you like your income paid on?

Choose any day between 1st and 28th

How often do you want your income paid? *

Do you want to take your income as a set amount or as a percentage of the original amount invested?

A set amount

A percentage of the original investment

Withdrawals of more than 5% a year of the amount paid into this policy could lead to a higher rate tax charge in the year of withdrawal

£

%

Tick to declare

I/We are the legal owner(s) of the policy quoted above.

I/We authorise ReAssure Limited to make the changes requested in this form.

We’ll complete your request as soon as possible and we’ll confirm that we’ve made your changes to you in writing.

If your withdrawal date is in the next two weeks the change may take effect in the month after you submit your request.

If there’s anything further that we need we’ll be in touch.