DIY Legal Forms

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Change Of Beneficiary Notice

Date:

To:

Dear _______,

BE IT ACKNOWLEDGED, that [Name] of [Address], is hereby designated beneficiary in and to a certain life insurance policy numbered [Number] and issued by [Name].

Said policy is dated [Date], the present death benefit payable is in the amount of [$------] on the life of the undersigned. This change of beneficiary acknowledgment terminates all prior designations of beneficiary heretofore made.

Please forward any necessary change of beneficiary forms.

Signed under seal this [Date].

Signature

Insured

Address

This Section for Notary:

Acknowledgment

STATE OF ____________

COUNTY OF __________

On [Date] before me, [Name], personally appeared, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

WITNESS my hand and official seal.

Signature

Affiance

[ ] Known

[ ] Unknown

ID Produced:

(Seal)