Fillable Beneficiary Change E-Form (Page 3 of 3) in pdf

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BENEFICIARY CHANGE FORM

Section A - Policy Information (You Must Complete This Section)

Policy Number: ______________________ Insured: ________________________________ ________________________________

(First Name)

(Last Name)

Subject to the provisions of the policy and the rights of any Assignee on record with the company, it is requested that the beneficiary be changed as follows:

Section B – Primary Beneficiary Information (You Must Complete This Section) – Any Percentages Must Add to 100%

Name: ___________________________________ SS#: ____________________* Relationship: ____________________ Percent: _______%

(To Insured, or Date of Trust)

Address: ___________________________________________________ Phone: ____________________ Date of Birth: ________________

Name: ___________________________________ SS#: ____________________* Relationship: ____________________ Percent: _______%

(To Insured, or Date of Trust)

Address: ___________________________________________________ Phone: ____________________ Date of Birth: ________________

If you wish to designate more than two Primary Beneficiaries, attach a signed and dated sheet listing the additional beneficiaries including all details in this form and

identifying their role as a Primary Beneficiary. If the Percent field is left blank the company will assume you wish to divide the benefit into equal shares.

Section C – Contingent Beneficiary Information – Any Percentages Must Add to 100%

Name: ___________________________________ SS#: ____________________* Relationship: ____________________ Percent: _______%

(To Insured, or Date of Trust)

Address: ___________________________________________________ Phone: ____________________ Date of Birth: ________________

Name: ___________________________________ SS#: ____________________* Relationship: ____________________ Percent: _______%

(To Insured, or Date of Trust)

Address: ___________________________________________________ Phone: ____________________ Date of Birth: ________________

If you wish to designate more than two Contingent Beneficiaries, attach a signed and dated sheet listing the additional beneficiaries including all details in this form

and identifying their role as a Contingent Beneficiary. If the Percent field is left blank the company will assume you wish to divide the benefit into equal shares.

Section D – Endorsement (The Policy Owner Must Complete This Section)

Acknowledgment of this change is not an admission that the policy/contract is in benefit or that the person(s) signing the change request is/are the owner(s). A

recorded change, not signed by the owner(s), may not constitute a valid change of beneficiary.

X __________________________________________ Owner’s SS#: _________________* Owner’s Phone: _____________________

Signature of Current Policy Owner/Assignor (Required)

(Required)

____________________________________ X__________________________ X _________________________________________

Signature of Co-Owner/Spouse (If Applicable)**

Primary Owner’s Date of Birth (Required)

Signature & Title of Assignee/Irrevocable Beneficiary (If Applicable)

Date: __________________ X ______________________________________

Notary Stamp/Seal

(Required)

Signature of Witness/Notary Public (If Applicable)

(If Applicable)

*Under penalties of perjury, I, the Owner, certify that: The numbers shown in this document are correct social security or taxpayer identification numbers, and I am not subject to backup

withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all interest

or dividends, or (c) the IRS has notified me that I am not subject to backup withholding. I am a U.S. Citizen or resident alien or a domestic business entity. (If you are not a U.S. citizen or a U.S.

resident alien, or a domestic business entity for tax purposes, please cross out this certification, complete and return IRS form W-8BEN, which can be located on )

** If you reside in one of the community property states listed, your spouse’s signature is required. Community Property States: AZ, CA, GUAM, ID, LA, NV, NM, PR, TX, WA, WI. Unless we

have been notified of a community or marital property interest in this contract, if this space is unsigned, we will rely on good faith that no such interest exists and will assume no responsibility

for inquiry.

Beneficiary Change E-Form Page 3

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