3. CHANGE OF ADDRESS
p Insured p Owner p Payor
Complete Address (including Zip Code)___________________________________________________________________________
Phone Numbers (including Area Code): Daytime _________________ Cell _________________ Evening ___________________
Email Address____________________________________________________________________________________________
4. OWNERSHIP CHANGE
pI elect to change the owner of this certiicate/policy to the following individual and understand that all beneits, rights, and privi- leges incident to ownership of this certiicate/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 (including Area Code): 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.)
pI ____________________________, owner of this certiicate/policy would like to decrease my coverage amount to $ ________
6.LOST STATEMENT COVERAGE REQUEST
pPlease send Statement of Insurance Coverage.
pPlease send complete duplicate certiicate/policy.
Reason for request p Cannot locate p Never received p 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 _________________________________________________________ Date ____________________________
(Parent or guardian, if insured is a minor)
Signature of Owner _________________________________________________________ Date ____________________________
(Required if other than Primary Insured)
Owner’s Name (Please Print) ____________________________________________________________________________________
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.
The current owner’s spouse must also sign if current owner lives in a community property state (AZ, CA, ID, LA, NV, NM, TX, WA, & WI).
Spouse’s Signature __________________________________
Phone Numbers (including Area Code): Daytime _________________ Cell__________________ Evening _______________________
Owner’s Complete Mailing Address ______________________________________________________________________________