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Security National Life Insurance Company

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Policy Number: ___________________________________________ Soc. Sec. #: ________________________
Insured’s Name and Address: __________________________________________________________________
Date of Birth: ____________________________________________ Phone: ____________________________
Owner’s Name and Address: __________________________________________________________________
Soc. Sec. #: ______________________________________________ Phone: ____________________________
CHANGE OF BENEFICIARY —
(Please Mark Primary or Contingent)
I hereby authorize the beneciary for the policy referenced above to be changed to:
☐ Primary Beneciary
Name: __________________________________________________ Date of Birth: ______________________
Soc. Sec. #: ______________________________________________ Relationship: _______________________
Address: __________________________________________________________________________________
Phone #: ________________________________________________
☐ Contingent Beneciary
Name: __________________________________________________ Date of Birth: ______________________
Soc. Sec. #: ______________________________________________ Relationship: _______________________
Address: __________________________________________________________________________________
Phone #: ________________________________________________
Equally or to the Survivor(s) if more than one is named. This Change of Beneciary revokes all prior designations made and
is subject to all the terms and provisions of the policy, except that I request that any applicable endorsement requirement be
waived. This change is to become effective on the date shown below, once the change has been recorded in the Home Ofce
of Security National Life Insurance Company, but without prejudice to the Company on account of any action taken or per-
mitted by the Company before such recording.
☐ IRREVOCABLE, if checked.
_________________________________ __________________________________ ___________________
Signature of Owner Signature of Witness Date
RECORDED AT SECURITY NATIONAL LIFE INSURANCE COMPANY
By: _____________________________________________________ Date: _____________________________
Security National Life Insurance Company
P.O. Box 57220 | Salt Lake City, UT 84157-0220
Phone (801) 264-1060 | Toll Free (800) 574-7117 | Fax (866) 666-4450
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Security National Life Insurance Company

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Completed 18 August 2021

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