Fill and Sign the Change of Beneficiary Form

CHANGE OF BENEFICIARY FORM Name:_______________________________ Soc. Sec. No.:_____________ Date of Birth:__________________________ Address: ____________________________ City: _____________________ State: ____________________ Zip: ______________________ Insurance Company:___________________________ Policy #:_______ Insurance Company, _________________________, ("Company"), is hereby notified that I hereby change the beneficiary on the above referenced policy as provided below and the Company is directed to record such change the designated beneficiary on the above referenced policy. All previous beneficiary designations are hereby revoked. NAME RELATIONSHIP BIRTH DATE Primary Beneficiary (ies) ________________________ _________________ ____________ ________________________ _________________ ____________ ________________________ _________________ ____________ ________________________ _________________ ____________ Contingent Beneficiary (ies) ________________________ _________________ ____________ ________________________ _________________ ____________ ________________________ _________________ ____________ ________________________ _________________ ____________ GENERAL PROVISIONS Beneficiaries are designated as first, second, third, etc. A beneficiary or class of beneficiaries will receive proceeds of a death claim in the designated order. Relationships are in reference to the insured. Unless otherwise provided in the policy or an endorsement: (1) two or more class members will share proceeds equally; (2) surviving class members will share equally the proceeds to which a deceased beneficiary would have been entitled; or (3) if no beneficiary survives the insured, proceeds will be paid to the Insured's estate. A beneficiary will not share in any proceeds or benefits if: (1) the beneficiary dies within the number of days after the Insured's death as provided in the policy, if so provided; (2) the Company Home Office is not provided with proof of the Insured's death. If the beneficiary is not a natural person, the beneficiary must still exist at the time of the Insured's death. All beneficiaries' interests are subject to any assignment on record at the Home Office. Acceptance of this form by the Company shall not constitute an admission by the Company that the policy is in force, in the event same has been cancelled or lapsed. It is my intent and desire that this Change of Beneficiary be effective immediately upon being deposited in the regular U.S. Mail addressed to the Company. I waive any other provision of the Policy to the contrary. If a provision of the provides that a change of beneficiary shall become effective when received, or when recorded, or on some other date that the date this Change is signed, I waive such provisions and request the Company to waive same. IT IS UNDERSTOOD THAT IN ENDORSING A BENEFICIARY CHANGE, THE COMPANY ADMITS NO LIABILITY NOT ALREADY EXISTING UNDER THE TERMS OF THE POLICY AT DATE OF ENDORSEMENT. IF THE POLICY CONTAINS AN IRREVOCABLE BENEFICIARY PROVISION AND AN IRREVOCABLE BENEFICIARY HAS BEEN DESIGNATED BY THE INSURED, THAT BENEFICIARY MUST CONSENT TO THIS CHANGE SEPARATE FORM. ______________________________ SIGNATURE (Owner of Policy) DATE FOR COMPANY USE Recorded on this the ___ day of ____________, 20___.