Application Change Beneficiary Form – Fill Out and Use This PDF

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.

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.

Y218A_0204

Change of Beneficiary Form

Important!

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:

Class	Please Print	Date of Birth	Relationship to	Percentage of
	Full Name and Address of Each Beneficiary		Insured	Proceeds Payable
Primary
Beneficiary(ies)
Contingent
(secondary)
Beneficiary(ies)

■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.

IT IS AGREED THAT THE INSTRUCTIONS APPEARING ON THE PRIOR PAGE ARE PART OF THIS CHANGE OF BENEFICIARY FORM.

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

____________________________________________________

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

Mailing Directions (Please Print)

Return acknowledgment of change to:

__________________________________________________________

Name

__________________________________________________________

Address

__________________________________________________________

City

State

ZIP Code

Is this a new mailing address? ■ Yes ■ No