Fillable Change Of Beneficiary Form - Colonial Life printable pdf download

CHANGE OF BENEFICIARY FORM

(Please print all information clearly)

Named Insured __________________________________________________

Social Security Number _______________________

LAST

FIRST

Policy Number(s) ______________________________________________________________________________________________

Policyowner’s Name ______________________________________________

Social Security Number _______________________

LAST

FIRST

Policyowner’s Mailing Address (Address on file will be update to the address provided below)

Street Address ________________________________________________________

Email _________________________________

City ___________________________________

State __________

Zip ___________

Phone (_______) _____________________

*IMPORTANT – PLEASE READ BEFORE DESIGNATING A BENEFICIARY

The person(s) designated as Primary Beneficiary will receive any payable benefits. If the Insured outlives all Primary Beneficiaries designated,

any payable benefits will be made to the designated Contingent Beneficiaries. If the Insured outlives all named Primary and Contingent

Beneficiaries, any payable benefits will be made according to the terms of the policy. Contact us at 1.800.325.4368 if additional space is

needed to designate all desired beneficiaries.

Primary Beneficiary(s): All surviving Primary Beneficiaries will receive equal amounts of the proceeds (unless percentages or amounts are

indicated). If more than one Primary Beneficiary is named the total % must equal 100%.

Names

Relationship

Date of Birth

Social Security Number

(Last, First, MI)

(MM/DD/YY)

Contingent Beneficiary(s): If the Named Insured out-lives all Primary Beneficiaries, all surviving Contingent Beneficiaries will receive equal

amounts of the proceeds (unless percentages or amounts are indicated). If more than one Contingent Beneficiary is named the total % must

equal 100%.

Names

Relationship

Date of Birth

Social Security Number

(Last, First, MI)

(MM/DD/YY)



Grandchildren’s Clause:

Check this box to ensure that in the event a Primary or Contingent Beneficiary who is a son or daughter of the

insured is no longer living at the time of the Insured’s death, their portion of the policy proceeds will be paid equally to their surviving legal

children.

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.

I request this beneficiary designation replace all prior designations for the policy(s) listed above.

Signature of present policyowner ____________________________________________ Date ____________

MM/DD/YYYY

Signature of witness _____________________________________________________

Date ____________

Must be someone other than the insured, a designated beneficiary and the policyowner

MM/DD/YYYY

Print name and address of witness

_______________________________________________________________________________________________________________

Last

First

Street Address

City

State

Zip

Change Of Beneficiary Form - Colonial Life

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