The beneficiary designation will remain unchanged until the properly completed form is received and acknowledged in writing at our
Home Office. |
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If a change of beneficiary is desired on more than one |
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Trust (Inter Vivos Living Trust): |
The trust must be in effect |
certificate, a separate form should be completed for each |
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at the time the beneficiary designation is completed. It is |
certificate. |
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necessary to furnish the name of the trust, the date the trust |
Designate beneficiary(ies) by selecting the check box next to |
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was executed, who executed it, and the name of the trustee(s). |
the appropriate category(ies) and then complete requested |
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A final beneficiary must be named to receive the proceeds if |
information. |
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the trust is not properly qualified or fails to make claim within |
This change of beneficiary form, once acknowledged, will |
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120 days from the date of death. |
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automatically revoke all prior beneficiary designations. |
Trust under Insured’s Will (Testamentary Trust): |
The |
Therefore, even if a principal or contingent beneficiary is to |
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proceeds paid according to the Insured’s Last Will and |
remain, such beneficiary must be renamed on this form. |
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Testament. |
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The owner/applicant completing this form cannot specify how |
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A final beneficiary must be named to receive the proceeds if |
a beneficiary is to use the proceeds. |
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the trust is not properly qualified or fails to make claim within |
The proceeds for minor beneficiaries are held by the Society |
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120 days from the date of death. |
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until they attain legal age, unless a court-appointed guardian of |
Method of Settlement. All or part of the proceeds may be left |
the minor’s estate properly requests payment prior to that time. |
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with Modern Woodmen under a settlement option. |
If Deposit |
Beneficiaries for a minor Insured must always have an |
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at Interest or any Other Optional Method of Settlement is |
insurable interest in the life of the child. Insurable interest is |
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selected and a principal beneficiary (payee) is eligible to |
when an individual is responsible either in whole or in part for |
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receive payment but dies before any of the proceeds have |
the care and welfare of the child. A parent or a grandparent is |
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been paid, then, unless otherwise provided, the proceeds will |
automatically assumed to have an insurable interest in the |
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be paid to any then surviving principal beneficiaries; if none, to |
child’s life. |
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any then surviving contingent beneficiaries; if none, in one sum |
Named Individuals: |
When naming individual beneficiaries, |
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to the estate of the payee. |
If One Sum is selected and a |
print the full |
names |
of the desired principal and contingent |
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beneficiary is eligible to receive payment but dies before any of |
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the proceeds have been paid, then, unless otherwise specified, |
beneficiaries, |
their |
addresses, their |
relationships to the |
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the proceeds |
will |
be |
paid |
in one sum |
to the beneficiary’s |
Insured, dates of birth and Social Security numbers. Proceeds |
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estate. |
Deposit |
at Interest |
may |
not be |
selected |
for |
a tax |
will be paid |
equally |
to the surviving |
principal |
beneficiaries |
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qualified certificate, such as an IRA. |
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unless otherwise indicated. The proceeds will be paid to the |
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person(s) named in the contingent beneficiary section only if |
Signature Required. |
The person having legal control of the |
no principal beneficiary survives the |
Insured. |
If additional |
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certificate should sign the beneficiary change request using his |
space is needed, attach a signed and dated sheet. Note: This |
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or her full name. All signatures must be original. |
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space may also be used to name corporations, businesses, or |
Date. |
The application should be dated with the month, day |
charitable organizations. Include address, city, state and |
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and year it is signed. |
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taxpayer ID if applicable. |
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Witness. The signature should be witnessed by an adult other |
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than one named as a beneficiary. |
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Questions: |
Please contact |
your |
Modern |
Woodmen |