Request For Change Of Beneficiary Or Name Form printable pdf download

Form No. GG-17

Request for Change of

Northeast Regional Office

Midwest Regional Office

Norwell Regional Office

Western Regional Office

P.O. Box 26050

P.O. Box 8012

P.O. Box 9121

P.O. Box 2454

Beneficiary and/or Name

Lehigh Valley, PA 18002-6050 Appleton, WI 54913-8012

Norwell, MA 02061-9121

Spokane, WA 99210-2454

PLEASE TYPE or PRINT CLEARLY. (The Entire Form, Properly Completed, Signed and Dated by the Insured, must be submitted or the

changes cannot be Processed.)

PLANHOLDER

NAME

___________________________________________________________________________

GROUP PLAN NUMBER

STREET

________________________________________________________________

ADDRESS

CITY, STATE

________________________________________________________________

AND ZIP.

EMPLOYEE NAME (LAST, FIRST, M.)

CERT.#

SOCIAL SECURITY #

EMPLOYEE HOME ADDRESS (STREET, CITY, STATE, ZIP)

The Guardian Life Insurance Company is hereby requested to make the following changes:

(PLEASE COMPLETE THE APPROPRIATE SECTIONS ONLY.)

CHANGE IN BENEFICIARY: (Complete only to change the Beneficiary Designation); Include full proper name, relationship and social

security number of proposed beneficiary(s) – i.e. Mary A Doe, and relationship – i.e. husband, wife, friend, son, daughter.

If more than one Beneficiary is designated, settlement will be made in equal shares to such of the designated beneficiaries as survive the

Insured, unless otherwise provided herein. If no designated beneficiary survives the Insured, settlement will be made to the estate of the

Insured, unless otherwise provided in the Group Plan.

SIGNATURE OF INSURED

SIGNATURE OF WITNESS (SOMEONE OTHER THAN BENEFICIARY)

DATE

ALL SIGNATURES MUST BE IN INK

CHANGE IN BENEFICIARY’S NAME (Complete only if the name has been legally changed.)

FROM (WAS)

TO (NOW IS)

SOCIAL SECURITY #

DATE

CHANGE IN INSURED’S NAME (Complete only if the name has been legally changed.)

FROM (WAS)

TO (NOW IS)

SOCIAL SECURITY #

DATE

SIGNATURE OF INSURED

DATE

ANY CHANGES IN DEPENDENT STATUS AND/OR NAME OF INSURED SHOULD BE REPORTED TO THE GROUP FIELD

SUPPORT DEPARTMENT ON THE APPROPRIATE FORM

THIS SECTION TO BE COMPLETED BY THE GUARDIAN/or THE PLANHOLDER ONLY.

This is to certify that the following changes have been recorded in connection with the insurance evidenced by the above certificate.

The BENEFICIARY has been changed

The NAME of the BENEFICIARY has been changed

Recorded By ___________________________________________________________________________ Date ____________________

(11/98)

ATTACH TOP COPY TO THE ENROLLMENT FORM, SECOND COPY TO THE GROUP INSURANCE CERTIFICATE

Request For Change Of Beneficiary Or Name Form

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