Insurance Life Change Form

Insurance Life Change Form

Use this form to request changes to an existing life insurance policy. Complete all applicable sections and provide required supporting documentation. Changes requested herein will not be effective until accepted in writing by the insurer and may require underwriting review, evidence of insurability, or payment of any additional premium due.

1. Policy and Insured Information

Policy Number:

2. Requested Change(s)

Select all changes you are requesting. Provide required details in the fields provided. Supporting documentation may be required for certain changes (for example, certified name-change records or proof of identity).

Name change — Former name: New legal name:

Address change — New address:

Change of policy owner — New owner name:

Change beneficiary designation (complete Section 3)

Change coverage amount — Current amount: $ Requested amount: $ Requested effective date:

Change premium payment method — New method:

Change tobacco/nicotine use status — New status:

Correction to date of birth — Correct DOB:

Other change (describe):

3. Beneficiary Designation

Designate primary and contingent beneficiaries. If percentages do not total 100% for primary or contingent, insurer will rely on most recent valid designation or contact owner for clarification.

If additional beneficiaries are to be designated, attach a separate signed and dated sheet with the same formatting and include the policy number on each page.

4. Coverage, Riders and Policy Details

5. Medical, Occupational and Underwriting Declarations

Answer each question truthfully. A "Yes" response requires explanation and may require evidence of insurability or additional underwriting.

In the past 12 months, have you been hospitalized, had surgery, or received inpatient care? If yes, explain below.

In the past 5 years, have you been diagnosed with or treated for any chronic or serious condition (cardiac disease, cancer, stroke, diabetes, COPD, HIV/AIDS, etc.)? If yes, explain below.

6. Effect of Change and Exclusions

By submitting this form, the owner/insured acknowledges and agrees that:

1. No requested change will become effective until accepted in writing by the insurer. The insurer may require evidence of insurability, additional documentation, proof of identity, or payment of additional premium. Failure to provide truthful information may result in rescission, reduction of benefits, or denial of a claim as allowed by policy terms and applicable law.

2. Unless expressly modified by acceptance of this request, all terms, conditions, exclusions, and limitations of the existing policy remain in full force and effect.

3. Any change in beneficiary designation supersedes prior beneficiary designations only if accepted and recorded by the insurer. The insurer is not responsible for verifying the validity of documents submitted in support of this request beyond reasonable review.

7. Authorization and Consent

I authorize the insurer, its agents and representatives to obtain and exchange medical, prescription, and claims information, and to obtain information from employers, physicians, medical facilities, and other insurance companies as necessary to process this request. I understand that such information will be used for underwriting, policy administration, and claim determination as permitted by law.

8. Declaration and Signature

I declare that the information provided on this form is true, complete and correct to the best of my knowledge. I understand that any material misstatement or omission may result in denial of the requested change or adverse action on the policy. I certify that I have legal authority to request the changes indicated and that I will provide supporting documentation upon request.

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