Better Alternative Life Insurance Beneficiary Change Form (Online)

UNIVERSAL REQUEST FOR CHANGE FORM

Account Information
Only complete the section you wish to change. Complete a separate form for each life insurance account except for sections 2 & 3.
Account Number Product Type Insured Owner (If other than Insured)
Section Break
1. Change of beneficiary (Please see instructions on pages 3 and 4)I hereby revoke any previous designation of beneficiaries and request that the life insurance benefit payable at my death be paid in accordance with the designations below. If more than one beneficiary is designated in the same beneficiary class, payment shall be made in equal shares to the designated beneficiaries unless otherwise provided herein. We must be informed of any legal restrictions affecting your beneficiary designations. Note: To comply with the laws of your state, beneficiary changes on 5Star Life Insurance Company (5Star Life) forms, and not those changes contained in an insured's will or trust shall govern in cases of change. Beneficiary changes arising from a divorce are not binding on 5Star Life unless made in the above prescribed manner or referenced in a court order filed with 5Star Life prior to the death of the insured. If more space is needed for beneficiary designation, please add a separate signed and dated sheet.
PRIMARY BENEFICIARY(IES) CLASS
Full given name (First, Middle, Last) Percentage
SSN Relationship Date of Birth Sex
Email Phone Number
Complete Address (including Zip Code)
Full given name (First, Middle, Last) Percentage
SSN Relationship Date of Birth Sex
Email Phone Number
Complete Address (including Zip Code)
Full given name (First, Middle, Last) Percentage
SSN Relationship Date of Birth Sex
Email Phone Number
Complete Address (including Zip Code)
SECONDARY (OR CONTINGENT) BENEFICIARY(IES) CLASS
Full given name (First, Middle, Last) Percentage
SSN Relationship Date of Birth Sex
Email Phone Number
Complete Address (including Zip Code)
SECONDARY (OR CONTINGENT) BENEFICIARY(IES) CLASS
Full give name (First, Middle, Last) Percentage
SSN Relationship Date of Birth Sex
Email Phone Number
Complete Address (including Zip Code)
Full given name (First, Middle, Last) Percentage
Email Phone Number
Complete Address (including Zip Code)
2. CHANGE OF NAME
I elect to change the name of:
- Insured
- Owner
- Payor to the following:
Name before change
Name after change
Date of change
MM slash DD slash YYYY
Reason for change:
- Marriage
- Divorce
- Adoption
- Other
3. CHANGE OF ADDRESS
- Insured
- Owner
- Payor
Complete Address (including Zip Code)
Phone Numbers
Daytime Cell Evening
Email Address
4. OWNERSHIP CHANGE
I elect to change the owner of this certificate/policy to the following individual and understand that all benefits, rights, and privileges incident to ownership of this certificate/policy will be vested in the new owner.
New Owner (First, Middle, Last) Relationship
New Owner's Date of Birth (MM/DD/YYYY) SSN
Phone Numbers:
Daytime Cell Evening
New Owner's Complete Address (including Zip Code)
5. REQUEST TO DECREASE COVERAGE
(Not applicable for Group, Individual, or Executive Select Term. Please contact us with questions.) I __________________________, owner of this certificate/policy would like to decrease my coverage amount to $______________
6. LOST STATEMENT COVERAGE REQUEST
- Please send Statement of Insurance Coverage.
- Please send complete duplicate certificate/policy
Reason for request:
- Cannot locate
- Never received
- Other
SIGNATURES
Sign and date this form and forward to 5Star Life. We will acknowledge receipt by returning a date stamped copy to you.
Signature of Insured
(Parent or guardian, if insured is a minor)
Date
MM slash DD slash YYYY
Signature of Owner
(Required if other than Primary Insured)
Date
MM slash DD slash YYYY
Signature of New Owner
Contingent Owner (in the event owner predeceases insured) ______________________________ Please Note: The CURRENT owner MUST sign above to request this ownership change.
Date
MM slash DD slash YYYY
Phone Numbers:
Daytime Cell Evening
Owner's Complete Mailing Address (including Zip Code)
Email
This field is for validation purposes and should be left unchanged.