Form Ben-Cskc - Beneficiary Change Form Page 4
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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 4:
Signatures and Date
**Please Note: All policy owners must sign this Beneficiary Designation Form.
If this form is recorded by the Company, such recording does not mean that the Company has passed on the legal
adequacy or validity of the change. Please consult your own legal or tax advisor for any such determination.
Unless we have been notified of a community or marital property interest in this policy, we will assume that no such
interest exists and will assume no responsibility for inquiring whether such interest exists. By signing this form, the
policy owner agrees to indemnify and hold us harmless from the consequences of making the changes requested in this
document.
Owner Signature _____________________________________________
Date ___________________
(Required)
Joint Owner Signature ____________________________________________
Date ___________________
(if applicable)
Joint Owner Signature _____________________________________________
Date ___________________
(if applicable)
Witness Signature (only required in MA) ______________________________________
Date _____________________
*Signature of the policy owner in MA must be witnessed by someone over the age of 18, not related to the policy owner(s), and not a named
beneficiary.
If you have designated a beneficiary as irrevocable, the irrevocable beneficiary must sign this form. The irrevocable
beneficiary must also sign any future beneficiary change requests. Please see Instructions.
Signature of Irrevocable Beneficiary: __________________________________
Date __________________
(if applicable)
A confirmation of the change will be mailed to the owner’s address of record, unless one of the below options is
selected. If there is more than one owner, please designate one email address or fax number.
By selecting the email or fax option below, I understand that confirmation will not be sent in paper form.
____
I would like confirmation of this change, or any questions related to the requested change, securely emailed
to me at the email address provided below.
Email Address (Print)_____________________________________________________________________________
____
I would like confirmation of this change, or any questions related to the requested change, faxed to the fax
number below.
Fax Number_____________________________________________________________________________________
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BEN‐CSKC 02/14
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