Change Beneficiary

{Date}

To:       {Company Name}

            {Address}

            {City, State, Zip}

To Whom It May Concern:

I would like to change the beneficiary on my policy with your company, number {number}. The policy is dated {date}, payable in the amount of {amount}.

The new beneficiary on this policy is {name}. Please remove all reference to {old name}. {He/she} should no longer have any claim to this policy.

If there are forms I need to fill out to make this official, please send them to me as soon as possible.

Insured Printed Name		Insured Signature

Notary Seal: