Fillable MULTIPURPOSE CHANGE FORM Primerica Life Insurance Company All

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MULTIPURPOSE CHANGE FORM Primerica Life Insurance Company All

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MULTIPURPOSE CHANGE FORM
All needed signatures must be completed on the reverse side of this document.
POLICY OWNER ADDRESS CHANGE
Policy Owner Policy Number
New Address
City State ZIP Code
- -
- -
Day Phone Number Home Work Other
Evening Phone Number Home Work Other
NAME CHANGE Use only when current policyowner or insured(s) has legally changed his/her name.
n Policy Owner
n
Primary Insured
n
Insured Spouse
n
Other Insured
n
Child
Prior Name (First, Middle, Last)
New Name (First, Middle, Last)
Reason for Change (Marriage, Court Order, etc.)
TRANSFER OWNERSHIP
I, _________________________________________________, the owner of Policy # ______________________________ issued on the life of
Name of Present Owner
________________________________________________ transfer ownership of said Policy, along with all rights, title and interest in said Policy to:
New Owner (First, Middle, Last)
NEW OWNER MUST COMPLETE THE FOLLOWING
- - - -
Date of Birth Social Security Number Relationship to Insured
- - - -
Day Phone Number n Home n Work n Other Evening Phone Number n Home n Work n Other
Address
City State ZIP Code
OVER
Primerica Life Insurance Company
Executive Office: 1 Primerica Parkway
Duluth, Georgia 30099-0001
Client Services 1-800-257-4725
Personal RVP Line 1-800-737-5596
Access your policy at myprimerica.com
PLA-83 REV 4 02.19
CHANGE BENEFICIARY
If a group is named as beneficiary, you must name each individual of this group.
IF A MINOR (below the age of 18) IS LISTED BELOW, PLEASE UNDERSTAND THAT A FINANCIAL GUARDIANSHIP FOR
THE MINOR’S ESTATE WILL BE REQUIRED BEFORE POLICY PROCEEDS CAN BE RELEASED.
PRINCIPAL BENEFICIARY Principal Beneficiaries in equal shares to the survivor(s), unless otherwise directed under percentage.
1.
Name (First, Middle, Last) Social Security Number Percentage
Date of Birth Relationship to Insured Street Address, City, State, ZIP
2.
Name (First, Middle, Last) Social Security Number Percentage
Date of Birth Relationship to Insured Street Address, City, State, ZIP
3.
Name (First, Middle, Last) Social Security Number Percentage
Date of Birth Relationship to Insured Street Address, City, State, ZIP
4.
Name (First, Middle, Last) Social Security Number Percentage
Date of Birth Relationship to Insured Street Address, City, State, ZIP
CONTINGENT BENEFICIARY Contingent Beneficiaries in equal shares to the survivor(s), unless otherwise directed under percentage.
1.
Name (First, Middle, Last) Social Security Number Percentage
Date of Birth Relationship to Insured Street Address, City, State, ZIP
2.
Name (First, Middle, Last) Social Security Number Percentage
Date of Birth Relationship to Insured Street Address, City, State, ZIP
SPOUSE RIDER BENEFICIARY Spouse Beneficiaries in equal shares to the survivor(s), unless otherwise directed under percentage.
1.
Name (First, Middle, Last) Social Security Number Percentage
Date of Birth Relationship to Insured Street Address, City, State, ZIP
SPOUSE CONTINGENT BENEFICIARY Contingent Beneficiaries in equal shares to the survivor(s), unless otherwise directed under percentage.
1.
Name (First, Middle, Last) Social Security Number Percentage
Date of Birth Relationship to Insured Street Address, City, State, ZIP
OTHER MISCELLANEOUS CHANGES
AUTHORIZATION FOR CHANGES
7 ______________________________________________________ 7 ___________________________________________________
Signature of Current Policy Owner Date Signature of Primary Insured Date
7 ______________________________________________________ 7 ___________________________________________________
Signature of New Policy Owner, if applicable Date Signature of Spouse Insured Date
7 ______________________________________________________ 7 ___________________________________________________
Signature of Irrevocable Beneficiary, if any Date Signature of Witness or Agent & Solution # Date
PLA-83 REV 4 02.19
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MULTIPURPOSE CHANGE FORM Primerica Life Insurance Company All

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Completed 6 January 2022

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