Address, Name Or Third Party Changes Form - Genworth
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1Address, name or third party changes
Genworth Life and Annuity Insurance Company,
from
Genworth Life Insurance Company
Genworth Life Insurance Company of New York
†
and
Genworth Life & Annuity
Page 1 of 1
Genworth Life
Genworth Life of New York
• Complete the policy information section and any section(s) that pertain to the
P . O. Box 40016
change(s) you need
Lynchburg, Virginia 24506-4016
• Please print clearly and use blue or black ink and initial any alterations or corrections
Tel: 888 GENWORTH (436.9678)
Fax: 877 300.1280
Policy information
Policy number(s) use only the spaces needed
b
Insured/owner name(s)
Date of birth if applicable
b
b
Type of change
Change address information
Name
j Third party
j Owner
j Insured
j Beneficiary
b
Address
b
City
State
Zip
b
b
b
Email
Phone number
b
b
Change name
Change name from j Owner
j Third party
j Insured
j Beneficiary
b
Attach legal documentation
Change name to
for name changes, except due
b
to marriage or divorce.
Reason for name change
b
Change third party
Select one:
j Delete existing third parties*
j Add
j Replace
*I elect not to designate any person to receive the protection against unintentional lapse notice.
Protection against unintentional
lapse gives you the right to designate
Name
at least one person other than yourself
b
to receive notice of lapse or termination
Address
for nonpayment of premium.
b
City
State
Zip
b
b
b
Phone number
Signature
b
Your signature indicates you have read
Policy owner’s signature
Date mm/dd/yy
and understand all sections of this
form. If you are a Trustee, Attorney-
X
b
In-Fact, Guardian, Conservator
Joint policy owner’s signature(s) if applicable
Date mm/dd/yy
or other Fiduciary, you must sign
in your capacity: (e.g. Jane Smith,
X
b
Trustee) and attach relevant legal
documentation.
Signature of Joint Owner (if any) is
required, unless otherwise stated in
your policy.
†
Only Genworth Life Insurance Company of New York is licensed in New York.
42909Life 04/30/12
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