Gerber Life Insurance Company 445 State Street Fremont Michigan 49412

REQUEST FOR POLICY CANCELLATION

Please CANCEL Policy Number: _____________________ Insured Person: _____________________ I UNDERSTAND THAT I AM TO RETURN THE POLICY TO GERBER LIFE INSURANCE COMPANY WITH THIS REQUEST.* Reason for cancelling coverage (check one) ____ 30-Day Free Examination Period ____ Too Expensive ____ Coverage does not meet needs ____ Duplicate Coverage ____ Other (please explain): _________________ ___________________________________ ___________________________________ I AGREE THAT: This form shall be basis for cancellation of this policy. *_____ Check here if policy cannot be located for return to Gerber Life.

____________ Date

________________________________________________ Signature of Policyowner