G R E AT WESTERN
I N S U R A N C E C O M P A N Y
3434 Washington Blvd Ste. 100. • Ogden, Utah 84401 • 801-689-1401 Voice • 801-689-1391 Fax
POLICYHOLDERSERVICEREQUEST
OWNER (if other than insured)
POLICYNUMBER (one policy only)
◆CurrentPolicyownerMustSignandDateTheReverseSide0fThisForm.
1. Funeral Home Changes: |
❑ Remove |
❑ Change |
AddBeneficiary |
❑ Primary |
❑ Contingent |
RemoveBeneficiary |
❑ Primary |
❑ Contingent |
|
|
|
|
|
|
|
|
Name |
|
|
Age |
Name |
|
|
Age |
|
|
|
|
|
|
|
|
Social Security Number |
|
|
|
Social Security Number |
|
|
|
|
|
|
|
|
|
|
Relationship to Insured |
|
Phone Number |
Relationship to Insured |
|
Phone Number |
|
|
|
|
|
|
|
|
|
Address |
|
|
|
Address |
|
|
|
|
|
|
|
|
|
|
|
City, State, Zip |
|
|
|
City, State, Zip |
|
|
|
|
|
|
|
|
|
|
|
Proceeds will be paid in equal shares to all primary beneficiaries who survive the insured, but if none survive the insured, proceeds will be paid in equal shares to all contingent beneficiaries who are living. This changecancels any previous beneficiary designation or settlement agreement.
2.Name Change of: |
** Note:This change will NOT transferownershiprights ** |
❑ Insured |
❑ Owner |
|
|
|
___________________________________________________ |
__________________________________________________ |
From (Former Name–Please Print) |
|
|
To (New Name–Please Print) |
Reason for change: ___________________________________________________________________________________________ |
3.OwnershipChange: |
|
|
|
|
Newownersignhere;currentownersignreversesideofform. |
|
|
_________________________________ |
___________________________________ _________________________________ |
Print Name of New Owner |
Soc Sec # of New Owner |
Signature of New Owner |
____________________________________________________________ |
__________________________________________ |
|
Address of New Owner |
|
Witness(Non-FamilyMember) |
FormG121(0800) |
|
(OVER) |
|
|
POLICYNUMBER _____________________
4.IrrevocableAssignment of Benefits
As the owner of the life insurance referred to above, I hereby irrevocably assign and transferall the policy benefits and proceeds of such policy to _________________________________________________________________________________________
Mortuary Name
I make this irrevocable assignment of benefits in connection with a pre-paid funeral plan which I have entered into, and I under- stand fully the effect of this assignment and transfer.
Designation of a beneficiary by me before or after the date of this assignment is subjectto this assignment and transfer.
Itismyintention,asownerofthepolicyreferredtoabove,tocontinuetopaythepremiumsandtoretainownershipofthepolicy.
5.Would you like to take a policy loan?
Issue check for ❑$ _______________
or ❑ maximum amount available.
❑Make check payable to policyowner
❑Make check payable to _______________________________________________________________________________
LoanAgreement InconsiderationoftheloanmadebyGreatWesternInsuranceCompany,Iassignthepolicytothecompanyassolesecurityfor therepaymentoftheloanwithinterestsubjecttotheprovisionsofthepolicy. IcertifythatnoBankruptcyProceedings,attach- ment,taxorotherlienorclaimisnowpendingagainstmeandthatthepolicyhasnotbeenpreviouslyassigned.
6.Do you need to surrenderyourpolicy? Please submit policy. If policy is lost, mark this box ❑
Thecashsurrendervalueisrequestedandwillbeacceptedinfullpaymentandreleaseofallclaimsunderthepolicy.Thesur- renderwillbeeffectivewhenthisrequestisreceivedbytheCompanyatitsOfficeinOgden,Utah.
❑MakecheckpayabletoPolicyowner
❑Makecheckpayableto __________________________________________________________________________________
Icertifythatnobankruptcyproceedings,attachment,taxorotherlienorclaimisnowpendingagainstme,andthatthepolicyhas
notbeenpreviouslyassigned.
7. Address/Telephone Numberchange forcurrent policyowner:
_________________________________________________________________________________________________________
8.Additional Request (Any OtherChanges Not ListedAbove)
________________________________________________________________________________________________________
SIGNATURES
I/weagreethatmy/oursignature(s)belowshallapplytoeachrequestwhichhasbeencompletedoneithersideofthisform
_____________________________________________ |
_______________ |
___________________________________________ |
Witness(Non-FamilyMember) |
Date |
CurrentPolicyowner(ifownedbyacompany,showtitle) |
_____________________________________________ |
|
___________________________________________ |
IrrevocableBeneficiary/AssigneeSignature |
|
Spouse’sSignaturerequiredinaCommunityPropertyState |
|
|
(Ifnone,stateNONE–Formwillnot beacceptedunlesscompleted) |
|
|
|
|
RECORDEDATTHEHOMEOFFICEON _____________________ |
BY________________________________________________________________________ |