Annuity Insurance Beneficiary Change Statement

Policy Information

Policy/Contract Number Policy Owner Name Policy Owner Address

Phone Number

Email Address

Current Beneficiary Information

Current Primary Beneficiary(ies) Current Contingent Beneficiary(ies)

New Beneficiary Designation

Primary Beneficiary(ies) Full Name(s) Relationship to Owner Share Percentage Contingent Beneficiary(ies) Full Name(s) Relationship to Owner Share Percentage

Authorization

Signature of Policy Owner

Date

Print Name

Witness Signature (if required) Date