SAMPLE CHANGE OF BENEFICIARY ACKNOWLEDGMENT
Date: [date]
To: [insurance company name]
[address]
[city, state, zip]
Attention: [name, if known]
Dear [name if known, or department]:
THIS LETTER HEREBY ACKNOWLEDGES that [name of person
to become new beneficiary] of [full
address], is hereby designated as beneficiary of the life insurance
policy numbered [insurance policy number]
issued by [insurer, e.g. Aetna Casualty]. This
policy is dated [date policy executed], and
the present death benefit payable is in the amount of $[amount payable upon death of insured] on the life
of the undersigned.
This document terminates all prior designations of beneficiary previously
made.
Please forward any necessary change of beneficiary forms to the address of
the insured.
Signed under seal this [day, e.g. 1st] day
of [month], [year].
_______________________________
Signature
[full name of insured]
Insured's name
[address]
[city, state, zip]
Address
STATE OF _____________________
COUNTY OF ____________________
In _______________, on the _____________ day of ____________, 20___, before
me, a Notary Public in and for the above state and county, personally appeared
[tenant], known to me or proved to be the
person named in and who executed the foregoing instrument, and being first duly
sworn, such person acknowledged that he or she executed said instrument for the
purposes therein contained as his or her free and voluntary act and deed.
_______________________________ NOTARY PUBLIC
My Commission Expires: ________
(SEAL)
