Change Of Beneficiary

Date: ____________________

To: _____________________

Notice is hereby given to you to change the beneficiary on Policy No. ___________, 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: ____________________