Western Form Change Beneficiary – Fill Out and Use This PDF

CHANGE OF BENEFICIARY REQUEST INSTRUCTION SHEET

The following information must be provided on the Beneficiary Change form

Before completing the Beneficiary Change form please read these important instructions carefully:

Original owner’s signatures and date are required – Faxes will be accepted

A Primary beneficiary is always required. Primary or contingent must be clearly marked. One person cannot be both a primary and contingent beneficiary. All prior beneficiaries will be revoked if we receive complete information for each section. Example: If only the primary beneficiary designation section is complete, but the contingent beneficiary designation section is incomplete, we will only process the primary beneficiary designation section and reject the contingent beneficiary designation section. No change was done to the incomplete beneficiary designation section.

The contingent beneficiary section is to be completed even if it is to only restate the current contingent beneficiaries on the policy. (Failure to do so will result in any current contingent beneficiaries being removed).

Do not use decimals or fractions. Enter whole percentages only.

If designating more than one beneficiary, the percentages must total 100% for the primary and 100% for the contingent beneficiaries.

If naming a trust as beneficiary please include the trust date and include the Trustee Certification form.

All requests must be legible and in good order.

The Company reserves the right to refuse to record any change requests not meeting the Company’s requirements.

_____________________________________________________________________________

___________________________________________________________________________________________

CHANGE OF BENEFICIARY REQUEST

Revocable Beneficiary: The owner may change a revocable beneficiary at any time without the beneficiary’s consent.

Irrevocable Beneficiaries: If a beneficiary is to be considered Irrevocable please indicate this next to the beneficiaries name. The owner may NOT change the irrevocable beneficiary without the consent of the irrevocable beneficiary. An irrevocable beneficiary has a vested interest in the proceeds of the policy; therefore, the policy owner cannot exercise certain rights without the permission of the irrevocable beneficiary.

If additional space is required please attach a separate page with all required information (i.e., Policy No., Owner’s signature and Date).

If any beneficiary is NOT a U.S. Citizen please indicate the country(ies) of citizenship_____________________________

________________________________________________________________________________________________

Signature of the Owner in Massachusetts must be witnessed by someone non-related and other than a named beneficiary. Must be over 18 years of age.

Signature of Irrevocable Beneficiary ______________________________________ Date ________________________

This request may be mailed or faxed.

Please Note: If you reside(d) in one of the following community property jurisdictions (AZ, CA, ID, LA,NM, NV, TX, WA, WI, Puerto Rico and Guam), you may wish to consult with your legal or tax advisor prior to making changes to your policy.

FOR CORPORATIONS ONLY:

If the Owner is a corporation, complete the following corporate acknowledgement and submit a copy of the resolution of the Board of Directors authorizing execution of this Change of Beneficiary or complete the Entity Certification Form.

STATE OF _________________________ County of ________________________ on this ______ day of ______________, _______,

before me personally came ____________________________________, who being by me duly sworn, did depose and say that s/he

resides in _______________________________, that s/he is the _____________________________ of

_______________________________, the corporation described herein, and which executed this Change of Beneficiary; that s/he

knows the seal of said corporation; the seal affixed to said Change of Beneficiary is such corporation; that it was affixed by order of the Board of Directors; and that s/he signed her/his name thereto.

My commission expires___________________ Notary Public ___________________________________________________

_________________________________________________________________________________________________