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:  ________________________