Change Of Beneficiary Notice

Date: ______________________

To: _______________________

Dear ______________________,

BE IT ACKNOWLEDGED, that _________ of ______________, is hereby designated beneficiary in and to a certain life insurance policy numbered _______ and issued by _______. Said policy is dated _______, 20__, the present death benefit payable is in the amount of $ _____ on the life of the undersigned. This change of beneficiary acknowledgment terminates all prior designations of beneficiary heretofore made. Please forward any necessary change of beneficiary forms.

Signed under seal this _____ day of ________, 20 __.

______________________

Insured

______________________

Address

STATE OF ____________

COUNTY OF __________

On ____________ before me, _____________, personally appeared, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

WITNESS my hand and official seal.

_____________________

Signature

Affiance

____ Known

____ Unknown

ID Produced: _______________________

(Seal)