Form 00-Ps-343-F - Request For Change Of Beneficiary / Name Change Form Page 2
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2American General Life Insurance Company / The United States Life Insurance Company in the City of New York
Please complete and return to the Administrator’s Office:
American Insurance Administrators, P. O. Box 1149, Columbus, OH 43216-1149
REQUEST FOR CHANGE OF BENEFICIARY / NAME CHANGE FORM
Group Policy Number: ___ _______________________________
Certificate #: ____________________________
Insured: _________________________________________________________ Date of Birth: ______/______/________
Address: ________________________________________ City _____________________ State: _______ Zip________
Phone:________________
Email:_____________________________________ Soc. Sec.#: _______-_____-________
PRIMARY BENEFICIARY(S):
In accordance to the terms of the above policy, request is made for Change of Beneficiary to:
(Indicate Full Name and Relationship- Example: Jane Doe, Wife, and Not Mrs. John Doe)
Name: _______________________________________________________________
E Mail: _________________________________
Address: __________________________________________________________ ___
Date of Birth: ________/_______/____________
City/State/Zip __________________________________________________________
Social Security # ________/______/__________
Phone Number: _________________
Relationship: _________________________
Percentage: _____________________________
Name: _______________________________________________________________
E Mail: _________________________________
Address: __________________________________________________________ ___
Date of Birth: ________/_______/____________
City/State/Zip __________________________________________________________
Social Security # ________/______/__________
Phone Number: _________________
Relationship: _________________________
Percentage: _____________________________
CONTINGENT BENEFICIARY(S):
Name: _______________________________________________________________
E Mail: _________________________________
Address: __________________________________________________________ ___
Date of Birth: ________/_______/____________
City/State/Zip __________________________________________________________
Social Security # ________/______/__________
Phone Number: _________________
Relationship: _________________________
Percentage: _____________________________
If surviving the Insured. Unless otherwise provided herein, if more than one beneficiary is named, payment shall be made in equal shares to the beneficiaries
who survive the Insured; if no beneficiary survives the Insured, payment shall be made in accordance with the terms of the policy. The right to further change
the beneficiary is reserved without the consent of the beneficiary.
CHANGE IN NAME ONLY OF: ( ) INSURED ( ) BENEFICIARY – changing name of person already named as
beneficiary. Please do not use to change the beneficiary named.
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Reason for change:
Marriage
By Court Order
Divorce & resumption of Former Name
Former Name was: ____________________________________________________________________________
Present Name is: ______________________________________________________________________________
Date of qualifying event: _________________________________________________
In each case: Complete the Following Section
Note: This form must be signed by the Insured or Owner.
Insured’s
Signature: _________________________________________ City/State ____________________ Date______________
Witness: __________________________________________ City/State ____________________ Date______________
(SOMEONE OTHER THAN BENEFICIARY)
FOR INSURANCE COMPANY’S USE ONLY-ACKNOWLEDGEMENT OF CHANGE
The recording of the change(s) requested above is hereby acknowledged.
Date Recorded: ________________ By: _______________________________________________________
00-PS-343-F-Rev.11/13
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