Change Beneficiary

Retiree Information

Primary Beneficiaries

I wish to change my life insurance beneficiary(ies); following is a new list of ALL my beneficiaries. Any previously named beneficiary not listed on this form will be considered to have been removed. Complete all fields for each named beneficiary and indicate the percentage of your life insurance you wish the beneficiary to receive.

• Jane Doe (Beneficiary One) - 25% Remove
  First Name

  Last Name

  ---

  Address

  City

  State

  Zip Code

  ---

  Phone

  Social Security Number

  Relationship

  Percent of Benefit

  %
• Steve Doe (Beneficiary Two) - 25% Remove
  Remove

  First Name

  Last Name

  ---

  Address

  City

  State

  Zip Code

  ---

  Phone

  Social Security Number

  Relationship

  Percent of Benefit

  %

Total for primary beneficiary(ies) = 50%

Contingent Beneficiaries

I wish to change my life insurance beneficiary(ies); following is a new list of ALL my beneficiaries. Any previously named beneficiary not listed on this form will be considered to have been removed. Complete all fields for each named beneficiary and indicate the percentage of your life insurance you wish the beneficiary to receive.

• Jane Doe (Beneficiary One) - 30%
  Remove

  First Name

  Last Name

  ---

  Address

  City

  State

  Zip Code

  ---

  Phone

  Social Security Number

  Relationship

  Percent of Benefit

  %
• Steve Doe (Beneficiary Two) - 30%
  Remove

  First Name

  Last Name

  ---

  Address

  City

  State

  Zip Code

  ---

  Phone

  Social Security Number

  Relationship

  Percent of Benefit

  %

Total for contingent beneficiary(ies) = 50%

A power of attorney must grant specific authority, by the terms of the document or applicable law, to make or change a Beneficiary designation. If you have any questions, please call 1 (800)233-2576.

Declaration and Signature