Change Of Beneficiary Form - Colonial Life
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1
2CHANGE OF BENEFICIARY FORM
Policy Number(s) _______________________________________________________________________________________
Print Named Insured: _________________________________________________________ SSN _______ - _____ - ________
Print Policyowner’s Name: _________________________________________________________ SSN _______ - _____ - ________
LAST
FIRST
MI
Print Policyowner’s mailing address (address on file will be updated to the address shown below)
Street Address __________________________________________________________________________________________
City _____________________________________ State ________ Zip___________ Phone ( _____ ) _________ - __________
*IMPORTANT – PLEASE READ BEFORE DESIGNATING A BENEFICIARY
The person(s) designated as Primary Beneficiary will receive any payable benefits. If the Insured outlives all Primary Beneficiaries designated, any
payable benefits will be made to the designated Contingent Beneficiaries. If the Insured outlives all named Primary and Contingent Beneficiaries,
any payable benefits will be made according to the terms of the policy. Contact us at 1.800.325.4368 if additional space is needed to designate all
desired beneficiaries.
Print Name of Primary Beneficiary(s): All surviving Primary Beneficiaries will receive equal amounts of the proceeds (unless
percentages or amounts are indicated). If more than one Primary Beneficiary is named the total % must equal 100%.
Name(s)
%
Relationship to Insured Person Date of Birth
SSN
LAST
FIRST
MI
MM/DD/YYYY
Total % must equal 100%
Print Name of Contingent Beneficiary(s): If the Named Insured out-lives all Primary Beneficiaries, all surviving Contingent
Beneficiaries will receive equal amounts of the proceeds (unless percentages or amounts are indicated). If more than one
Contingent Beneficiary is named the total % must equal 100%.
Name(s)
%
Relationship to Insured Person Date of Birth
SSN
LAST
FIRST
MI
MM/DD/YYYY
Total % must equal 100%
Grandchildren’s Clause
( ) Please check this box to ensure that in the event a Primary or Contingent Beneficiary who is a son or daughter of the insured is no longer
living at the time of the Insured’s death, their portion of the policy proceeds will be paid equally to their surviving legal children.
Special Notice for Residents of a Community Property State
A spouse or former spouse may have an interest in life insurance proceeds or any accumulated cash value if the policy premiums were paid
with community funds. It is your responsibility to consult your legal advisor to 1) ensure that any required consent from a spouse or former
spouse has been received and 2) ensure that your spouse or former spouse will not be able to make a claim against any policy values and/or the
proceeds in the event any policy benefits become payable.
I request this Beneficiary Designation replace all prior designations for the policy(s) listed above.
____________________________________ ____ / ____/ ____ __________________________________ ____ / ____/ ____
Signature of Policyowner
Date
Signature of Witness
Date
(Must be someone other than the Insured,
a designated Beneficiary and the Owner)
Print Name and Address of Witness
______________________________________________________________________________________________________
LAST
FIRST
MI
STREET ADDRESS
CITY
STATE
ZIP
2/09
17075-14
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