Application Change Beneficiary Form PDF Details

Are you in the process of changing the beneficiary on one of your financial accounts? If so, you'll likely need to fill out an application change beneficiary form. This form allows you to designate a new beneficiary for the account in question. The process of filling out this form can seem daunting, but with a little guidance, it's definitely doable. In this blog post, we'll walk you through the steps involved in completing an application change beneficiary form. So, whether you're just getting started or are almost done, keep reading for helpful tips!

Form NameApplication Change Beneficiary Form
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesmutual of omaha change of beneficiary form, application change beneficiary, mutual of omaha life insurance change of beneficiary form, mutual omaha beneficiary

Form Preview Example

Application for Change of Beneficiary

Companion of New York

3316 Farnam Street

Omaha, NE 68175

Instructions for Completing the Change of Beneficiary Form

The Change of Beneficiary Form is attached. Examples of wording that can be used to designate a beneficiary on this Form are set forth below. If the policy proceeds are to be paid other than in a single sum, do not use this form and contact Companion Life Insurance Company for further instructions.

Type of Beneficiary

1. Executor or administrator . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2. Two or more named persons in equal shares . . . . . . . . . . . . . .

3. Two or more named persons in unequal shares . . . . . . . . . . .

4. Unnamed children of a specified marriage . . . . . . . . . . . . . . .

(excluding children by a previous marriage, foster children and stepchildren)

5. Trustee under Last Will and Testament of Insured . . . . . . . . . .

6. Other Trust Arrangements . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7. Corporation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8. Partnership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Instructions for Signing the Change of Beneficiary Form

Sample Wording

“Insured’s estate”

“John Doe, father, and Mary Doe, mother, in equal shares” “40% to John Doe, father, and 60% to Mary

Doe, mother” — [do not use dollar amounts] “Children of the marriage of the Insured and Jane Doe”

“Trustee, or successor in Trust, named in the Last Will and Testament of the Insured; provided, however, that if no Trustee is appointed

within one year of the Insured’s death, payment shall be made to the Insured’s estate” “Professional Trust Company, Trustee, or its successor in Trust, under Trust

Agreement dated Jan. 1, 1982” “XYZ, Inc., a New York corporation” “ABC Company, a partnership”

Who Must Sign: The Change of Beneficiary Form must be signed by the person or persons who, under the terms of the policy, have the right to change the beneficiary. If the previous beneficiary was designated as an irrevocable beneficiary, that beneficiary must also sign.

How to Sign: Each signature must be witnessed by a disinterested person or persons. If signed by:

(a)a corporation, the full corporate name should be written, followed by the signature(s) and title(s) of the officer(s), other than the Insured, who is/are authorized to sign on behalf of the Corporation. [NOTE: Please submit a certified copy of the Board of Directors resolution authorizing the change or the Trust Certification form];

(b)a partnership, the full name of the partnership should be written and followed by the signature of the authorized partner(s) [NOTE: Please submit a copy of those pages of the partnership agreement showing the authorized partner(s) names and signature(s)].

If signed with an “X” mark or in foreign characters, the signature must be witnessed by two witnesses and the address of each witness must be given.

Changing a beneficiary will not change the ownership of the policy. The interest of any beneficiary will be subject to the interest of any collateral assignee under a collateral assignment on record with the Company.


Change of Beneficiary Form


1.Complete, sign and return this form for each Policy and/or Policy rider for which you are requesting a change.

2.Please use full given names (for example, “Mary E. Doe” and not “Mrs. John E. Doe”).

3.Do not send the Policy with this form unless we instruct you to do so.

4.Forms cannot be accepted which contain corrections or erasures.

Name ofPolicy

Insured: ___________________________________________________ Number: _________________________________________

As Policyowner, I hereby revoke any previous Beneficiary designation and election of settlement, I request that, on the death of the Insured named above, all proceeds of the Policy and/or rider(s) covering the named Insured be paid to the following beneficiary or beneficiaries as shown below:


Please Print

Date of Birth

Relationship to

Percentage of


Full Name and Address of Each Beneficiary



Proceeds Payable









































Irrevocable Primary Beneficiary (ies): If this Box is checked, the Policy will be endorsed to show that the Primary Beneficiary (ies) named above is/are irrevocable. Changes to the Policy and/or rider(s), including a change of beneficiary (ies), may not be made by the Policyowner(s)/Trustee(s) without the consent of the Irrevocable Primary Beneficiary (ies) shown above.

Unless otherwise shown above: (a) payment will be shared equally by all Primary Beneficiaries who survive the Insured; if none, by all Contingent Beneficiaries who survive the Insured; (b) the right to change the beneficiary is reserved unless otherwise stated; (c) payment shall be made in a single sum; and (d) the word “child” or “children” shall include legally adopted children.


The Company reserves the right to declare this form void and of no effect if it is incomplete or completed in an unsatisfactory manner.

Dated at ________________________________________________ this ___________ day of ___________________ , _________

City and State




Area Code

Phone Number of Policyowner


Signature of Policyowner(s)/Trustee(s) (If the Policyowner is a corporation or partnership, include authorized signature(s)


Signature of all Irrevocable Primary Beneficiary(ies) (if applicable) prior to submitting this Form

Mailing Directions (Please Print)

Return acknowledgment of change to:








ZIP Code

Is this a new mailing address? Yes No