Form Ben-Cskc - Beneficiary Change Form Page 3
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4Monumental Life Insurance Company
Beneficiary
Stonebridge Life Insurance Company
Change Form
Transamerica Life Insurance Company
Western Reserve Life Assurance Company of Ohio
Fax Number 1-800-297-9120
Administrative Office located at: 4333 Edgewood Rd. NE, Cedar Rapids, IA 52499
Section 3:
Contingent Beneficiary Information
Contingent beneficiary: Receives proceeds only if no primary beneficiary(ies) survives the insured.
Primary and contingent beneficiaries cannot be the same.
Contingent Beneficiary(ies)
If this section is left blank, current contingent beneficiary designations will be revoked.
Name _________________________________________________________________________________________
share equally
Relationship _________________________________________________ Birth or Trust Date________________
OR
Address ______________________________________________________________________________________
City/State/Zip _________________________________________________________________________________
________%
Phone Number___________________________________ SSN or Tax ID Number ________________________
Name _________________________________________________________________________________________
share equally
Relationship _________________________________________________ Birth or Trust Date________________
OR
Address ______________________________________________________________________________________
City/State/Zip _________________________________________________________________________________
________%
Phone Number___________________________________ SSN or Tax ID Number ________________________
Name _________________________________________________________________________________________
share equally
Relationship _________________________________________________ Birth or Trust Date________________
OR
Address ______________________________________________________________________________________
City/State/Zip _________________________________________________________________________________
________%
Phone Number___________________________________ SSN or Tax ID Number ________________________
Name _________________________________________________________________________________________
share equally
Relationship _________________________________________________ Birth or Trust Date________________
OR
Address ______________________________________________________________________________________
City/State/Zip _________________________________________________________________________________
________%
Phone Number___________________________________ SSN or Tax ID Number ________________________
Contingent Beneficiary Percentage Total (must equal 100%)
_________%
PLEASE SIGN AND DATE FORM ON PAGE 3
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BEN‐CSKC 02/14
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Parent category: Legal