Elect/change Of Beneficiary Form
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2Elect/Change of Beneficiary Form
Structured Settlements
Introduction
Instructions
Use this form to make beneficiary changes to a John Hancock Structured Settlement Contract. John Hancock Life Insurance
Company USA and John Hancock Life Insurance Company of New York are herein referred to as "John Hancock".
Questions about this form?
Contact us:
See end of document
7
1-617-572-0355
1-866-275-5477
for return instructions
1. Contract Information
Payee Name (First)
(MI)
(Last)
Phone Number
Certificate Number
Social Security Number (or TIN)*
Date of Birth
*While the information is optional, we encourage you to provide it so we can
properly identify the contract.
2. Acknowledgement
I,
__________________________________________,
hereby
revoke
all
previous
beneficiary designations under
Full Name
the above contract number and designate the following beneficiary (or beneficiaries) effective on or after
________________ to receive any death benefit payable under the terms of the above contract. I reserve the right to make
Date
further beneficiary designations.
3. Beneficiary Designations
Primary Beneficiary:
1..
Primary Beneficiary Name (First)
(MI)
(Last)
Date of Birth
Relationship
Social Security Number
2..
Primary Beneficiary Name (First)
(MI)
(Last)
Date of Birth
Relationship
Social Security Number
Issuer: John Hancock Life Insurance Company (U.S.A.), Lansing, MI (not licensed in New York)
Issuer in NY: John Hancock Life Insurance Company of New York, Valhalla, NY
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