Beneficiary Designation
Use this form to nominate or change a beneficiary for certain refunds of premium upon death of the policyholder. It can be completed
by clients who:
• purchase an optional Return of Premium Benefit rider (if available), or
• are eligible for the Return of Premium upon Death Under Age 65 Benefit.
Otherwise, such refunds will be made payable to a surviving spouse/partner (if any), or to your estate.
This is NOT an assignment of benefits for claims reimbursement.
Introduction
Questions about this form?
1-800-377-7311
See the end of this document
for
return
instructions
To email this form:
8 LTCForms@jhancock.com
1. Policyholder Information
Insured's Signature
Today’s Date (MM/DD/YYYY)
SIGN
HERE
LTC-3663 11/18
John Hancock Life Insurance Company (U.S.A.), Boston, MA 02117 (not licensed in New York) and in New York by
John Hancock Life & Health Insurance Company, Boston, MA 02117
Middle Last
State
Zip
First
Street
City
Email Address:
Insured’s Name:
Insured's Address:
Policy Number(s):
Phone Number:
2.
Beneficiary Information
Last
State
Zip
Street
City
Date of Birth:
New Beneficiary Change Beneficiary
Social Security
Number or TIN:
Phone Number:
MM/DD/YYY
3. Authorization
Submission Instructions
Need more information? Call:
Monday through Friday
8:00 A.M. to 6:00 P.M. Eastern Time
John Hancock Long-Term Care: 1-800-377-7311
TTD Hearing/Speech Impaired: 1-800-832-5282
To email this form:
8 LTCForms@jhancock.com
To fax this form:
7 1-617-572-6010
To mail this form:
+ John Hancock Financial Services
PO Box 55978
Boston, MA 02008-5978
Middle
First
Name:
Address:
