Policy Service Form - Beneficiary
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BENEFICIARY
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Guarantee Trust Life Insurance Co.
POLICY SERVICE FORM – BENEFICIARY
PLEASE PRINT
Date: ___________________________
Insured: _________________________________________________
Policy No.: _______________________
Owner: __________________________________________________________________________________________
Owner’s Phone Number:
(____)_____________________
Mailing Address of Owner:
_______________________________________________________________________
Number and Street
_______________________________________________________________________
City
State
Zip Code
q
Check box if this is a new address.
1) Complete this section to add or change a Beneficiary
– I understand that with this change I will terminate all
previous beneficiary selections for this policy. The beneficiary selection will be as shown below. You may name more
than one Beneficiary.
Primary Beneficiary
___________________ _______________________________________________
1.
Full Name
Address
___________________ ____________
________
____________________
1.
Relationship to Insured
Date of Birth
% of proceeds
Social Security No.
___________________ _______________________________________________
2.
Full Name
Address
___________________ ____________
________
____________________
2.
Relationship to Insured
Date of Birth
% of proceeds
Social Security No.
Contingent Beneficiary:
(You may name a contingent who would collect the policy benefits if the primary beneficiary
(s) was not living at the time of the insured’s death.)
1. _________________________ __________________________________________________________
Full Name
Address
___________________ ____________
________
___________________
1.
Relationship to Insured
Date of Birth
% of proceeds
Social Security No.
___________________ ______________________________________________
2.
Full Name
Address
___________________ ____________
________
___________________
2.
Relationship to Insured
Date of Birth
% of proceeds
Social Security No.
Note: If two or more beneficiaries are named above (Primary or Contingent) all surviving beneficiaries will SHARE equally
in any payments due, unless the % of proceeds is shown.
* You have the option to designate your Primary Beneficiary as an Irrevocable Beneficiary. This means the Beneficiary
designation could not be changed without Beneficiary’s signature.
2) This section must be signed by the Policy Owner in order to process your request.
I agree this form is a request and authorization to change my current policy record.
________________________
Date:
______________________________________________________________________
Owner’s signature:
For Company Use Only:
The above request for change is acknowledged and has been completed by the Company. This acknowledgement
applies only to the policy specified in the form.
Date Completed: __________________
Policy No.: _____________________________
Signature: ______________________________________________
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