Lifesecure Beneficiary Change Form – Fill Out and Use This PDF

I DIRECT THAT ANY ENDORSEMENT OF THE POLICY REQUESTED BE EFFECTED BY RETURN OF THIS REQUEST WITH THE COMPANY'S ACKNOWLEDGMENT. I AGREE THAT THE COMPANY MAY WAIVE ANY POLICY PROVISION REQUIRING PRESENTATION ON THE POLICY FOR ENDORSEMENT, BUY MAY REQUIRE SUCH PRESENTATION IF DESIRED.

FOR ADMINISTRATIVE OFFICE USE ONLY

ACKNOWLEDGMENT OF REQUEST FOR CHANGE - PLEASE ATTACH TO POLICY

THE ABOVE COMPANY HAS RECORDED THE CHANGE REQUESTED

*BE SURE TO HAVE THE POLICYOWNER'S SIGNATURE WITNESSED BY SOMEONE WHO IS NOT A RELATIVE OR BENEFICIARY

INSTRUCTIONS FOR CHANGING BENEFICIARY

THE FULL LEGAL NAME AND RELATIONSHIP TO THE INSURED OF EACH PRIMARY AND CONTINGENT BENEFICIARY IS TO BE CLEARLY SHOWN. FOR EXAMPLE, MARTHA BROWN SMITH (WIFE) AND NOT MRS. JOHN H. SMITH (WIFE).

IF THE POLICY IS ASSIGNED, THE ASSIGNEE MUST JOIN IN SIGNING THE CHANGE OF BENEFICIARY AGREEMENT. THE CHANGE OF BENEFICIARY AGREEMENT MUST BE DATED, AND YOUR SIGNATURE AND THAT OF THE ASSIGNEE MUST BE WITNESSED BY A RESPONSIBLE ADULT.

ALL SIGNATURES ARE TO BE IN INK. THE CHANGE WILL BE RECORDED BY US AND A COPY WILL BE RETURNED TO THE OWNER. PLEASE DO NOT SEND US YOUR POLICY.

THE POLICYOWNER REVOKES ANY PREVIOUS DESIGNATION OF BENEFICIARY AND METHOD OF SETTLEMENT FOR THE POLICY. RECORDING THE INSTRUMENT THE COMPANY AGREES, THAT THE CHANGE OF BENEFICIARY REQUESTED SHALL BECOME EFFECTIVE UPON RECEIPT AND RECORDING OF THIS PROPERLY COMPLETED FORM BY THE COMPANY, DURING THE LIFETIME OF THE INSURED, AT ITS HOME OFFICE IN AUSTIN, TEXAS; AND SUBJECT TO THE PROVISIONS OF THE POLICY.

WHEN MORE THAN ONE PRIMARY BENEFICIARY IS NAMED, PAYMENT SHALL BE MADE SHARE AND SHARE ALIKE, SURVIVORS AND SURVIVOR. THIS SIMILARLY APPLIES WHEN MULTIPLE CONTINGENT BENEFICIARIES ARE NAMED AND BECOME ENTITLED TO THE PROCEEDS OF THIS POLICY.

IF A CHANGE OF BENEFICIARY IS DESIRED ON MORE THAN ONE POLICY, COMPLETE A SEPARATE FORM FOR EACH POLICY. FOR EACH INSURED COVERED UNDER ONE POLICY, COMPLETE A SEPARATE FORM.

PLACE AN "X" IN ONLY ONE OF THE BOXES NUMBERED 1 OR 2 AND INDICATE THE DESIRED BENEFICIARY IN THE SPACE PROVIDED. IF MORE THAN ONE BOX IS MARKED, THE FORM WILL BE RETURNED FOR CLARIFICATION AND PROCESSING WILL BE DELAYED. GIVE THE FULL NAME (FIRST NAME, MIDDLE INITIAL, AND LAST NAME) AND ADDRESS OF THE DESIRED BENEFICIARY (IES) AND THE RELATIONSHIP, IF ANY, OF EACH TO THE INSURED AND THE DATE OF BIRTH. FOR DESIGNATION NUMBER 2, PROVIDE THE TRUST NAME AND GIVE THE DATE OF THE TRUST AGREEMENT.

IMPORTANT:

PLEASE PROVIDE THE NAME, ADDRESS, SOCIAL SECURITY NUMBER AND THE RELATIONSHIP TO THE INSURED FOR EACH BENEFICIARY, OR IF THE CLASS OF BENEFICIARIES IS NAMED, THE NAME OF EACH CURRENT BENEFICIARY IN THE CLASS.