Sbli Change Form – Fill Out and Use This PDF

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Beneficiary Change Form

Policy Number(s):

Name of Insured:

Name of Policyowner(s):

(if other than insured)

Beneficiary Change Section

When designating multiple beneficiaries in the same class, the proceeds will be paid in equal shares, unless otherwise indicated. To designate specific percentages among the beneficiaries indicate the percentage to be paid to each beneficiary under the percentage of benefits section below. The total of all percentages within each class must equal 100%. If any beneficiary within the same class does not survive the Insured, any share due to that beneficiary will be paid proportionately to the beneficiaries within the same class, unless otherwise specified. If designating “Children of the Insured", the designation includes only lawful children born to or legally adopted by the Insured.

In lieu of payment as now provided, I hereby request that the net proceeds payable under each of the above policies in the event of the Insured's death be paid as follows:

Class 1 - Primary Beneficiaries

Beneficiary Name and Address	% of Benefits	Relationship to Insured	Social Security #
(Required)	(Optional)	(Required)	(Required)
Name:
Address:
Name:
Address:
Name:
Address:

Class 2 - Contingent Beneficiaries

Beneficiary Name and Address	% of Benefits	Relationship to Insured	Social Security #
(Required)	(Optional)	(Required)	(Required)

Name:

Address:

Name:

Address:

Name:

Address:

Time Clause to be effective? □ Yes □ No (If not answered, the Time Clause will NOT be effective.)

If the time clause option is chosen, any beneficiary who survives the Insured but dies prior to 15 days after the Insured's date of death shall be deemed not to have survived the Insured.

No beneficiary shall be permitted to commute, anticipate, encumber, alienate or assign any of the payments due hereunder, except as above provided, nor shall the same be in any way subject to such person's debts, contracts or engagements, nor to any judicial processes to levy upon or attach the same for payment thereof. All decisions made by SBLI in good faith as to the identity of beneficiaries not designated by name shall be conclusive as to the liability of SBLI and any payment made in accordance therewith shall, to the extent thereof, discharge SBLI of its obligation for such payment.

I hereby request that SBLI waive any requirement that this change be endorsed on the policy. I agree that the change herein requested shall be assumed to become effective without such endorsement, and I further agree that acknowledgment of receipt of this form by SBLI shall be construed as a waiver of the requirement of any such endorsement without further acknowledgment or notice by it.

Date: ________________

Signature of Policyowner: ____________________________________________________

SIGNATURE OF DISINTERESTED WITNESS: I hereby certify under the penalties of perjury that I am over 18 years of age, a disinterested party who will not benefit from this policy and have witnessed the signing of this form by the policyowner.

Date: ________________

Signature of Disinterested Witness: ____________________________________________

** If the previous Beneficiary on this policy has been designated “irrevocable” or “without power of revocation”, that Beneficiary must sign below.

Date: ________________

Signature of Previous Beneficiary: _____________________________________________

DO NOT MAIL POLICY

When processed, an acknowledgment will be sent to you for your records

K-107

07/2017)

Instructions for Beneficiary Change

What you should know before completing this form?

Class 1 - Primary Beneficiaries -

This section is used to designate the person, persons or entity who will be the primary recipient(s) of the proceeds.

If all beneficiaries designated in this class do not survive the Insured, proceeds will be paid to the beneficiaries designated in “Class 2 - Contingent Beneficiaries”.

Class 2 - Contingent Beneficiaries -

This section is used to designate the person, persons or entity who will be the contingent recipient(s) of the proceeds, only if there are no surviving beneficiaries in Class 1.

If there are no surviving beneficiaries under either class, proceeds are payable to the Owner or the estate of the Owner, otherwise to the estate of the Insured.

Using Percent (%) of Benefits -

When designating multiple beneficiaries in the same class, you can also indicate the percent of benefits to be paid to each person or entity. To designate specific percentages among the beneficiaries indicate the percentage to be paid to each beneficiary under the percentage of benefits section. The total of all percentages within each class must equal 100%. If any beneficiary within the same class does not survive the Insured, any share due to that beneficiary will be paid proportionately to the beneficiaries within the same class, unless otherwise specified.

Beneficiary Address and Social Security Number -

The beneficiary(ies) Address and Social Security Number will help us locate him or her if there is a future claim under the policy.

This information will only be used if we cannot locate the beneficiary using any other method. In the event of a discrepancy, the beneficiary's name and relationship will take precedence over this information.

Effect of Time Clause -

If the time clause option is chosen, any beneficiary who survives the insured but dies prior to 15 days after the Insured's date of death shall be deemed not to have survived the Insured.

Completing the form

1.Complete the enclosed form to designate or make changes to the current beneficiary(ies). The information on this form will replace any prior beneficiary designation on the policy(ies).

2.Print the full name, address and relationship (to the Insured) of each beneficiary designated. The Social Security Number is optional and will only be used in the event of the Insured's death. This information will only be used if we cannot locate the beneficiary using any other method. However, if designating a Corporation or Charity, we require the name, address, and taxpayer I.D. # for the Corporation or Organization.

3.Percentage (%) of Benefits only needs to be completed if the proceeds will not be shared equally among all beneficiaries designated in the same class. (Percentages must total 100% for each class) If percentage is not indicated, the proceeds will be paid in equal shares among the surviving beneficiaries within the same class.

4.The Policyowner must date and sign the request for a beneficiary change. In addition, we require all Owner signatures for beneficiary change requests to be witnessed. The witness must be a disinterested third party who is not the Insured, Owner or designated as a beneficiary to the policy and is least 18 years of age.

5.In the event that the previous beneficiary designation was irrevocable (named "without power of revocation") or if the policy was issued prior to 12-15-39 and the right to change the beneficiary was not reserved, the previous beneficiary must also sign the request, thereby agreeing to the requested change.

Please do not mail the policy(ies) with your request, an acknowledgment of the change will be sent to you for your records.

If you have any questions regarding this form, please feel free to contact out Customer Service Call Center at 800-694-7254.

Return completed form to:	The Savings Bank Mutual Life Insurance Company of Massachusetts
	P.O. Box 4048
	Woburn, MA 01888

K-107

07/2017)