Life Insurance Change of Beneficiary Agreement
Policy Information
Policyholder Name
Policy Number
Insured Person (if different)
Current Beneficiary Information
Current Primary Beneficiary Name
Relationship to Policyholder
New Beneficiary Information
Full Name
Relationship to Policyholder
Percentage (%)
Date of Birth
Address
Contingent Beneficiary (Optional)
Full Name
Relationship to Policyholder
Percentage (%)
Address
Agreement
I hereby request and authorize the change of beneficiary as indicated above and certify that all information provided is accurate to the best of my knowledge.
Signature of Policyholder
Date:
Witness (if required)
Date: