Change Of Ownership Form - Colonial Life

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CHANGE OF OWNERSHIP FORM
(Please print all information clearly)
Named Insured __________________________________________________
Social Security Number _______________________
LAST
FIRST
MI
Policy Number(s) ______________________________________________________________________________________________
Present Policyowner’s Name _______________________________________
Social Security Number _______________________
LAST
FIRST
MI
Colonial Life & Accident Insurance Company is hereby requested to amend the above Policy(s) so as to provide that, during the lifetime
of the Insured, the right to change the beneficiary and all other rights, benefits, options and, privileges conferred by the Policy and any
rights conferred by a rider attached to the Policy or allowed by the Company, including the right to assign and the right to receive
endowment proceeds, if any belong exclusively to:
New Policyowner’s Name ___________________________________________ Social Security Number _______________________
LAST
FIRST
MI
Relationship _____________________________
DOB ____________________
Email ____________________________________
MM/DD/YYYY
Street Address _____________________________________
City _____________________
State __________
Zip ___________
First Contingent Policyowner’s Name __________________________________ Social Security Number _______________________
LAST
FIRST
MI
Relationship _____________________________
DOB ____________________
Email ____________________________________
MM/DD/YYYY
Street Address _____________________________________
City _____________________
State __________
Zip ___________
Second Contingent Policyowner’s Name ________________________________ Social Security Number _____________________
LAST
FIRST
MI
Relationship _____________________________
DOB ____________________
Email ____________________________________
MM/DD/YYYY
Street Address _____________________________________
City _____________________
State __________
Zip ___________
Provided, however, upon the death of the above named person(s), if other than the Insured, the interest of such person(s) shall pass to the
estate, unless otherwise provided herein. This request shall not constitute any change of beneficiary or settlement agreement and the
interest of the above named person shall be subject to the interest of any creditor beneficiary, any assignee of record with the Company and
any beneficiary with respect to whom the right to change the beneficiary has not been reserved. Acceptance of this request by Colonial Life &
Accident Insurance Company shall constitute an amendment of the policy.
Special Notice for Residents of a Community Property State: A spouse of 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 proceeds in the event any policy benefits become payable.
Payment Method Change (Complete this section only if there is a change in how premiums will be paid.)
Please deduct premiums from my checking account
Your checking account will be drafted monthly for your premium payments. Please attach a voided check and indicate which day of
th
the month you would like the account to be drafted. Draft date must be no later than the 26
of each month. The checking account
owner’s signature is required.
Signature of checking account owner _____________________________________________
Draft date ________________
Please bill me directly (Choose one of the following)
Quarterly (3x the monthly premium)
Semi-annually (6x the monthly premium)
Annual (12x the monthly premium)
Payroll deduction (A payroll deduction card must be complete.)
Signature of present policyowner ____________________________________________ DOB ____________ Phone # ____________
MM/DD/YYYY
Signature of new policyowner ______________________________________________
DOB ____________ Phone # ____________
MM/DD/YYYY
Signature of witness _____________________________________________________
DOB ____________ Phone # ____________
MM/DD/YYYY
Witness address _______________________________________________________________________________________________

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