LONG-TERM CARE INSURANCE THIRD PARTY/AUTHORIZED
DESIGNEE CHANGE FORM
The Company You Keep
®
NEW YORK LIFE INSURANCE COMPANY, LONG-TERM CARE
P.O. Bo
x 64670
St. Paul, MN 55164-0670
New York Life Insurance Company (New York Life) requires written notice of changes in the status of
your third party designee.
Please check the appropriate box below, complete the information in the appropriate section,
sign and date the form, and return the form to New York Life. If you have any questions, please
contact the Long-Term Care Call Center at (800) 224-4582.
Insured Name: _____________________________ Account Number: ______________
If you currently have a designee, provide the designee’s information below.
Current Designee Information:
Name of Designee (Please Print)
Street Address (Please Print)
City State Zip
I wish to update my designee information.
Designee Information:
Name of Designee (Please Print)
Street Address (Please Print)
City State Zip
I wish to terminate my current designee and I do not wish to designate another.
Signature of Insured Date
Designee Chg (VSC) (0119)
