Modern Woodmen 948 Form – Fill Out and Use

Final Beneficiary: Name ________________________________________________________

Relationship

_____________________

Trust under Insured’s Will. Final Beneficiary: Name ___________________________________

Relationship

_____________________

Final Beneficiary: Name ________________________________________________________

Relationship

_____________________

Trust under Insured’s Will. Final Beneficiary: Name ___________________________________

Relationship

_____________________

Form 948 (Rev. 3-12)

*00869*

(SEE PAGE 2 FOR CHANGE OF NAME)

Marriage

Adoption

Divorce

Other (Specify): _________________________________________________

If selecting Other, please provide copy of legal documentation.

X_____________________________________________________

Date ______________________________________

Signature of Insured or Owner

Month

Day

Year

Home Office.

 If a change of beneficiary is desired on more than one



Trust (Inter Vivos Living Trust):

The trust must be in effect

certificate, a separate form should be completed for each

at the time the beneficiary designation is completed. It is

certificate.

necessary to furnish the name of the trust, the date the trust

 Designate beneficiary(ies) by selecting the check box next to

was executed, who executed it, and the name of the trustee(s).

the appropriate category(ies) and then complete requested

A final beneficiary must be named to receive the proceeds if

information.

the trust is not properly qualified or fails to make claim within

 This change of beneficiary form, once acknowledged, will



120 days from the date of death.

automatically revoke all prior beneficiary designations.

Trust under Insured’s Will (Testamentary Trust):

The

Therefore, even if a principal or contingent beneficiary is to

proceeds paid according to the Insured’s Last Will and

remain, such beneficiary must be renamed on this form.

Testament.

 The owner/applicant completing this form cannot specify how

A final beneficiary must be named to receive the proceeds if

a beneficiary is to use the proceeds.

the trust is not properly qualified or fails to make claim within

 The proceeds for minor beneficiaries are held by the Society



120 days from the date of death.

until they attain legal age, unless a court-appointed guardian of

Method of Settlement. All or part of the proceeds may be left

the minor’s estate properly requests payment prior to that time.

with Modern Woodmen under a settlement option.

If Deposit

 Beneficiaries for a minor Insured must always have an

at Interest or any Other Optional Method of Settlement is

insurable interest in the life of the child. Insurable interest is

selected and a principal beneficiary (payee) is eligible to

when an individual is responsible either in whole or in part for

receive payment but dies before any of the proceeds have

the care and welfare of the child. A parent or a grandparent is

been paid, then, unless otherwise provided, the proceeds will

automatically assumed to have an insurable interest in the

be paid to any then surviving principal beneficiaries; if none, to

child’s life.

any then surviving contingent beneficiaries; if none, in one sum

 Named Individuals:

When naming individual beneficiaries,

to the estate of the payee.

If One Sum is selected and a

print the full

names

of the desired principal and contingent

beneficiary is eligible to receive payment but dies before any of

the proceeds have been paid, then, unless otherwise specified,

beneficiaries,

their

addresses, their

relationships to the

the proceeds

will

be

paid

in one sum

to the beneficiary’s

Insured, dates of birth and Social Security numbers. Proceeds

estate.

Deposit

at Interest

may

not be

selected

for

a tax

will be paid

equally

to the surviving

principal

beneficiaries

qualified certificate, such as an IRA.

unless otherwise indicated. The proceeds will be paid to the



person(s) named in the contingent beneficiary section only if

Signature Required.

The person having legal control of the

no principal beneficiary survives the

Insured.

If additional

certificate should sign the beneficiary change request using his

space is needed, attach a signed and dated sheet. Note: This



or her full name. All signatures must be original.

space may also be used to name corporations, businesses, or

Date.

The application should be dated with the month, day

charitable organizations. Include address, city, state and



and year it is signed.

taxpayer ID if applicable.

Witness. The signature should be witnessed by an adult other

than one named as a beneficiary.



Questions:

Please contact

your

Modern

Woodmen

Form 948B (Rev. 3-12)

(SEE PAGE 1 FOR CHANGE OF BENEFICIARY)