Form Lp-159 - Beneficiary Change Form
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3Banner Life Insurance Company
3275 Bennett Creek Avenue
BENEFICIARY CHANGE FORM
Frederick, Maryland 21704
(Please Print Clearly)
(800) 638-8428
Policy Number: ______________________________
Insured: _______________________________________________
1.
The policy proceeds payable upon the death of the insured will be paid to the benefi ciaries named herein. The rights of the
benefi ciary will be subject to the rights of any assignee on record. If no percentage is provided, proceeds will be divided equally
among all surviving benefi ciaries. All prior revocable designations of Primary and Contingent benefi ciaries are hereby revoked.
Primary Benefi ciary
(If additional space is needed, please attach a separate page, signed and dated. SSN or Tax ID
# and Date of Birth are REQUIRED.)
Name ____________________________________________________
SSN or Tax ID # ___________________
Address ___________________________________________________
Date of Birth ______________________
City, State __________________________________ Zip ____________
Telephone # ______________________
Relationship to Proposed Insured _______________________________
% Share _________________________
Name ____________________________________________________
SSN or Tax ID # ___________________
Address ___________________________________________________
Date of Birth ______________________
City, State _________________________________ Zip _____________
Telephone # ______________________
Relationship to Proposed Insured _______________________________
% Share _________________________
Name ____________________________________________________
SSN or Tax ID # ___________________
Address ___________________________________________________
Date of Birth ______________________
City, State __________________________________ Zip ____________
Telephone # ______________________
Relationship to Proposed Insured _______________________________
% Share _________________________
Name ____________________________________________________
SSN or Tax ID # ___________________
Address ___________________________________________________
Date of Birth ______________________
City, State _________________________________ Zip _____________
Telephone # ______________________
Relationship to Proposed Insured _______________________________
% Share _________________________
Name ____________________________________________________
SSN or Tax ID # ___________________
Address ___________________________________________________
Date of Birth ______________________
City, State __________________________________ Zip ____________
Telephone # ______________________
Relationship to Proposed Insured _______________________________
% Share _________________________
LP-159 (7-12)
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