Insurance Spousal Document

INSURANCE SPOUSAL CONSENT AND ACKNOWLEDGMENT

Insured / Policy Information

Insured Name:   Policy Number:

Policy Type: Life Health Disability Long-Term Care Other

Coverage Amount: $   Deductible: $   Premium: $

Policy Effective Date:   Policy Period From: to

Spouse / Consenting Party Information

Date of Birth:   Phone:   Email:

Beneficiary Designation / Change

Current Primary Beneficiary Name:

Coverage Selection and Exclusions

Applicable Coverages (select all that apply): Life Insurance Accidental Death & Dismemberment Critical Illness Income Protection

Spousal Consent, Waiver and Acknowledgment

I, the undersigned spouse, acknowledge that I am legally married to the Insured identified above. I have read the proposed change to the beneficiary designation and understand that by signing this document I am providing my voluntary and informed consent to the requested action concerning the policy identified above.

I expressly consent to the designation of the proposed beneficiary(ies) and, to the extent permitted by applicable law, I knowingly and voluntarily waive any marital, community property, elective share, or similar right that I may have in respect of the proceeds of the policy as altered by the requested beneficiary designation. I understand that this waiver is intended to be effective immediately upon acceptance by the insurer and that it relinquishes rights that I might otherwise assert against the Insured, the designated beneficiary(ies), or the insurer.

I represent and warrant that I am of legal age and mentally competent to execute this document and that I am signing of my own free will without coercion, duress, or undue influence. I understand that the insurer may rely upon this consent and that the insurer shall not be liable for acting on the beneficiary designation in reliance upon this document.

Documentation Checklist

Required documentation submitted with this consent: Marriage certificate or equivalent proof of marriage Government-issued photo identification for spouse Proof of beneficiary relationship (if requested) Other supporting documentation (describe below)

Certification and Authorization

By signing below I certify under penalty of perjury under the laws of the applicable jurisdiction that the information provided on this form is true and correct to the best of my knowledge. I authorize the insurer and its representatives to verify any information contained herein and to request and review any supporting documentation necessary to effectuate this consent.

I understand that this consent may be reflected in the insurer's policy records and that any revocation of this consent must be made in writing and may be subject to the terms and conditions of the policy and applicable law.

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