CHANGE OF BENEFICIARY
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.