Fill and Sign the Beneficiary Life Form

Request for Change of Beneficiary of Life Insurance Policy To: ______________________________________ (Name of Insurance Company) ______________________________________ ______________________________________ (Street address, city, county, state, zip code) In accordance with the provisions of Policy No. ___________, I elect to change the sole beneficiary to be as follows: (Name New Beneficiary, Date of birth, and Relationship to insured) . _____________________ ______________ _________________________ I request that this change be endorsed on the Policy. By this election I revoke all other and former designations. I make this election subject to all of the conditions and provisions of the Policy as well as any existing assignment and, unless otherwise provided by me in this Application for Change of Beneficiary, I expressly reserve the full and absolute right to make other and further changes at any time I may elect. It is understood and agreed that all decisions upon questions of fact in determining any unnamed beneficiaries in this agreement designated, made by the Company in good faith, based on proof by affidavit or other written evidence satisfactory to it, shall be conclusive and fully protect the Company in acting in reliance thereon. I represent and certify that no insolvency or bankruptcy proceedings are now pending against me. Upon endorsement of the change of beneficiary as above requested, the Policy should be returned to ________________________________________________________________ _______________________________________________ (Name of Owner of Policy, Street address, city, county, state, zip code) . Witness my signature this the _______________________ (date) . ___________________________________ (Name and Signature of Owner of Policy) (Acknowledgments may be optional and form may vary by state) STATE OF _________________ COUNTY OF _______________ Personally appeared before me, the undersigned authority in and for the said county and state, on this _____ day of ______________, 20_____, within my jurisdiction, the within named, __________________________________ (Name of Owner of Policy), who acknowledged that he executed the above and fore going instrument. ___________________________ NOTARY PUBLIC My Commission expires: ______________________