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: ________________________
