CHANGE OF BENEFICIARY

Date: ____________________

To: _____________________

Notice is hereby given to you to change the beneficiary on Policy Number __________

of _________________________________________________. The policy was issued by ______________________________________________ (hereinafter "company").

Subject to the provisions attached and marked as Exhibit A, the beneficiary is to be changed from _________________________________, of _____________________,

to _________________________________, of ______________________________.

This request for change of beneficiary shall take effect as of the day it is signed, accepted, and recorded at the home office of the company. Any previous selection of a

beneficiary is hereby revoked.

Signed: ________________________