Insurance Benefit Modification Form

INSURANCE BENEFIT MODIFICATION FORM

Use this form to request a modification to existing policy benefits. Completion of this form does not constitute approval. All modifications are subject to underwriting review, receipt of any required documentation, and payment of any applicable premium or fees.

Insured / Applicant Information

Insured Name:   Policy Number:

Date of Birth:   Phone:   Email:

Policy Information

Policy Type: Term Life Whole Life Disability Health

Requested Modification

Effective Date Requested:

Modification Type (select all that apply): Increase Coverage Amount Decrease Coverage Amount Change Deductible Change Beneficiary Add Rider Remove Rider

Beneficiary Information (if applicable)

Complete allocations must total 100%. If additional beneficiaries are required, attach a separate sheet signed by the applicant.

Relationship:   Allocation %:   DOB:

Relationship:   Allocation %:   DOB:

Coverage Options & Riders

Select rider options to add or remove: Accidental Death (AD&D) Waiver of Premium Long-Term Care Child Term

Documentation Checklist

Attach required documentation; incomplete submissions delay processing.

Copy of government-issued ID
Proof of insurability/medical evidence (if requested)
Signed beneficiary designation form (if applicable)
Court documents or legal instrument (if required)

Exclusions, Conditions and Effect of Modification

The insurer reserves the right to accept, modify, or decline any requested change. Acceptance of a modification may require underwriting review, medical evidence, and payment of any additional premium. No modification is effective until accepted by the insurer in writing and any required premium payment is received. Changes requested that conflict with policy terms will be processed in accordance with the policy contract language.

Misstatements, omissions or fraudulent statements in this request may void the modification and can affect coverage. The insurer may obtain medical records and other information necessary to evaluate this request; by signing below the applicant authorizes release of such information to the insurer and its authorized representatives.

Certification and Authorization

By signing below, I certify that the information provided in this Insurance Benefit Modification Form is true and complete to the best of my knowledge. I understand that authorization of the requested modification is subject to insurer approval and that premiums or benefits may be adjusted in accordance with underwriting determination and policy terms. I authorize the insurer to release and obtain information as necessary to process this request, and I acknowledge that changes may have tax or legal consequences for which I am solely responsible.

For Insurer Use Only

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