Change of Name or Beneficiary Form

Change of Name or Beneficiary

THE BEACON INSURANCE CO.LTD IS HERBY REQUESTED: *

Change NameIssue a Duplicate Certificate (Group Life)

Group Policy Number *

Certificate Number

Only if requested for group life

Please check the appropriate box, complete the information required under the appropriate request, and in each case, complete (4) below.

(THIS FORM TO BE COMPLETED IN DUPLICATE)

1. REQUEST FOR CHANGE OF BENEFICIARY (GROUP LIFE, A.D. & D. AND HEALTH In accordance with the terms of the above policy, request is made for Change of Beneficiary to

First Name *

Middle name

Last Name

Email *

Relationship *

if surviving the Insured. Unless otherwise provided herein, if more than one beneficiary is named, payment shall be made in equal shares to the beneficiaries who survive the Insured, if no beneficiary survives the Insured payment shall be made to such persons in such order of preferences as constitute the legal laws of the beneficiaries. The right to further change the beneficiary is reserved unto the Insured without the consent on the beneficiary. It is warranted that this insurance is not now assigned.

Address of Beneficiary if not related to the Insured

2. REQUEST FOR CHANGE IN NAME (GROUP LIFE, A.D.& D. AND HEALTH) The name of the Insured has been changed for the reason shown below. Please make an Endorsement to this effect on your records

FORMER NAME WAS *

PRESENT NAME IS *

Reason for Change

MarriageDivorced and Resumption of Former NameBy Court OrderName Incorrect on Certificate

Witness Name *

Someone other than the beneficiary