Be sure to show the Policy Number and Insured’s Name at the top of this form. Use a separate form for each Policy. Restate the entire
designation, even if only changing a part of the designation. If additional space is required, please attach a separate page (including
Policy Number, Date Signed, and Owner’s Signature.)
INDIVIDUAL(S) - The current Owner(s) must sign on the line provided for “Owner’s Signature.”
BUSINESS ENTITY- One officer other than the Insured must sign below the name of the company. The officer’s title (President,
General Manager, Vice President, Secretary, etc.) must follow the signature. A corporate resolution or other supporting documentation
is required to support each officer’s signature. If the insured is the sole officer of the company, we will require a statement on company
letterhead signed and dated by that officer and witnessed by a least one other person, that the insured is the sole officer and that
he/she is authorized to act on behalf of the company. If a partnership is the owner, at least two authorized partners must sign below
the name of the partnership and the title “Partner” must follow each signature.
TRUST - The complete name and date of the trust should be listed. Individual trustees must sign and add wording similar to the
following: “John Doe, trustee under XYZ Trust dated June 1, 1984.” Corporate Trustees must sign and add wording such as “ABC
Bank, trustee under XYZ Trust dated June 1, 1984; John Doe, Trust Officer”, and a corporate resolution or other supporting
documentation is required to support each corporate trustee officer’s signature. For changes to trust owned policies, a completed
Verification of Trust Agreement for Life Insurance Policies (dated within the previous twelve (12) months) must be submitted with the
applicable change form.
IRREVOCABLE BENEFICIARIES - Any irrevocable beneficiary must sign subsequent beneficiary designation changes and may be
required to sign other requests for changes to or disbursements from the Policy.
GUARDIAN OR CONSERVATOR – A court-appointed guardian of the estate or conservator may sign on behalf of the Owner. Certified
copies of the letters of guardianship/conservatorship and/or the court order that authorizes the change must also be submitted.
AGENT ACTING UNDER A POWER OF ATTORNEY - An agent acting under a power of attorney may sign on behalf of the Owner. A
complete copy of the Power of Attorney document, the Questionnaire to Accompany Power of Attorney, and the Affidavit of Agent for
Power of Attorney must be submitted by the agent. If a complete copy of the Power of Attorney documentation has been submitted to
us within the previous twelve months, an additional copy may not be required.
COMMUNITY PROPERTY STATES - Unless we have been notified of a community or marital property interest in this Policy, we
will assume that no such interest exists and will assume no responsibility for inquiring whether such interest exists. By signing this form,
the Policy owner agrees to indemnify and hold us harmless from the consequences of making the changes requested in this document.
COLLATERAL ASSIGNMENTS - If the Policy has been assigned, a representative of the collateral assignee must also sign the form.
A corporate resolution should be provided if the assignee is a business entity, subject to the Business Entity signature requirements
stated above. Payment of proceeds to any beneficiary is subject to the interest of any assignee on the Policy.
IF A BENEFICIARY DIES - The interest of any beneficiary who dies before the Insured will terminate at his/her death. The interest of
any beneficiary, who dies at the time of, or under certain policies within 30 days after, the Insured’s death, will also terminate if no
proceeds have been paid to the beneficiary. If the interest of all named beneficiaries has terminated (including contingent beneficiaries,
if named), any proceeds payable will be paid to the Owner of the Policy. If the Owner is not living at that time, any proceeds payable
will be paid to the executor or administrator of the Owner’s estate.
TRUST/MINOR BENEFICIARIES - If a trust is named beneficiary, the Company shall not be responsible for the disposition by the
trustee of any proceeds paid to the trustee. Any payment to a minor beneficiary shall be made to the legally appointed guardian of the
estate or conservator of the minor, unless otherwise permitted by law.
Requests for special settlement arrangements, other than those specified in the Policy, may be sent to the Company for review and
assistance with preparation of the proper beneficiary designations.
SAMPLE BENEFICIARY DESIGNATIONS:
PERCENTAGES: Do not specify dollar amounts. Please use
percentages totaling 100% for primary and contingent
designations. Primary beneficiaries should total 100% and
contingent beneficiaries should independently total 100%.
ONE PRIMARY AND ONE CONTIGENT:
Primary: Jane Doe, Spouse
Contingent: John Doe, Jr., Son
Estate of Insured
XYZ Trust, dated ________________; ABC Bank, Anytown,
CA 12345, Trustee
SPOUSE OF INSURED, OTHERWISE CHILDREN:
Primary: Jane Doe, Spouse
Contingent: John Doe, Jr., Son, and any other children born to
or adopted by the Insured (currently living children must be
Primary: Jane Doe, Spouse, irrevocably designated
TWO BENEFICIARIES IN UNEQUAL AMOUNTS:
Primary: Jane Doe, Mother 75%; John Doe, Brother, 25%
PER STIRPES DESIGNATIONS:
Primary: Jane Doe, Spouse
Contingent: Equal shares to John Doe, Jr., Son and Mary Doe,
Daughter, per stirpes.
Primary: ABC Co., Inc., Creditor, a California Corporation, its
successors and assigns, as its interest may appear; remainder,
if any, to Jane Doe, Spouse.
John Doe, Creditor, his successors and assigns, otherwise to
the Executor or Administrator of his Estate, all as their interest
may appear; remainder, if any, to Jane Doe, spouse.
TRUSTEE UNDER LAST WILL AND TESTAMENT:
Primary: The trustee or successor trustee, under the Last
Will and Testament of the Insured. If the Insured should
die intestate or if no
trust is created by the Insured’s Last Will
and Testament, then to the Executor or Administrator of the