Beneficiary change request

Clear Form Clear Kit

Policy/Certificate Number(s)

Section 1: Insured
First Name Middle Name Last Name

c Please check if not the primary insured.

Permanent Address: City, State, Zip Code c Please check if you would like the address listed to Phone Number
be the address of record for the policy.

Date of Birth (mm/dd/yyyy) Social Security Number/Tax Identification Number (TIN)

The policy proceeds payable upon the death of the insured for each policy listed above will be paid to the beneficiaries named herein.

Section 2: Owner (if different than Insured)

If there are multiple owners, please designate one address for all policy correspondence to be mailed to since our administrative
systems will only allow one address for mailing. Please note: If you do not indicate an address for mailing, the first owner listed will
become the nominee owner and receive all correspondence.
First Name Middle Name Last Name

Permanent Address: City, State, Zip Code c Please check if you would like the address listed to Phone Number
be the address of record for the policy.

Date of Birth (mm/dd/yyyy) Social Security Number/Tax Identification Number (TIN)

Section 3: General Provisions

I hereby revoke all previous beneficiary designations and change the beneficiary(ies) according to section four (4) of this form.

The new beneficiary designations are

c Revocable c Irrevocable (If no box is checked, the beneficiary designation will be revocable):
• Irrevocable beneficiary designations require the signature of the irrevocable beneficiary in section five (5). If you choose an irrevocable
beneficiary, written consent is required before any future changes can be made.

• Please complete the form(s) in their entirety to avoid delays in processing.

• Please use percentages in your designation - fractions and dollar amounts are not accepted. Designations must equal 100%.

Continued on Page 2

*L2402* *L-2402*
®
North American Company for Life and Health Insurance | New Business Processing Center: P.O. Box 5088, Sioux Falls, SD 57117 | Principal Office: West Des Moines, IA
Phone: 877-872-0757 | Fax: 877-208-6136 | NorthAmericanCompany.com
L-2402 Page 1 of 5 REV 5-23
• All beneficiary changes MUST include the designation of a Primary Beneficiary. Even if you only want to change the Contingent Beneficiary, you
must restate the Primary Beneficiary.

• To distribute proceeds “per stirpes” please check the box. Per Stirpes is a common way of distributing proceeds where if one or more of your
beneficiaries has died, his or her children share equally in his or her share of the proceeds (also known as Right of Representation). If per
stirpes is selected it is required to attach a separate page listing the names, social security numbers, date of births, address and phone numbers
for all children.

• Contingent Beneficiaries will receive death benefit proceeds in the event that the Primary Beneficiary predeceases the insured and if the primary
designation did not include “per stirpes”.

• If you need additional space or wish to designate more than four beneficiaries, attach another sheet marked “Attachment.” Each attachment
must contain policy number(s) and be signed and dated.

• If the owner is a Company or Plan, please provide a current list of those authorized to sign on the company’s behalf. The form must be signed
by two authorized representatives (signors).

• If a legal representative signs for the Owner, supporting legal documentation must accompany the form.

• Any payment to a minor beneficiary will be held with the Company until the state’s age of majority or until Legal Guardianship of the minor’s
Estate is established or unless otherwise permitted by law.

• If the Insured’s Estate is selected as Primary Beneficiary, a Contingent Beneficiary does not apply.

• If the owner resides in Massachusetts, the owner’s signature must be witnessed by a disinterested person over 18 who is not being named
beneficiary.

• In order to distribute proceeds accurately and according to your wishes, provide the current phone number, address, email address, social
security number for each Beneficiary. If we do not receive all of this information, we will send a follow-up letter requesting the missing
information.

®
North American Company for Life and Health Insurance | New Business Processing Center: P.O. Box 5088, Sioux Falls, SD 57117 | Principal Office: West Des Moines, IA
Phone: 877-872-0757 | Fax: 877-208-6136 | NorthAmericanCompany.com
L-2402 Page 2 of 5 REV 5-23
 Section 4a: Primary Beneficiary(ies)
*Fields are required for processing the Beneficiary Change request.
NOTE: Percentage (%) of proceeds for Primary Beneficiary(ies) must equal 100%
Name* Percentage*
%
Date of Birth (mm/dd/yyyy)* Relationship* Phone Number

Street Address City State Zip

Social Security Number/TIN Number*

Please distribute the proceeds “Per Stirpes” c

Email Address

Name* Percentage*
%
Date of Birth (mm/dd/yyyy)* Relationship* Phone Number

Street Address City State Zip

Social Security Number/TIN Number*

Please distribute the proceeds “Per Stirpes” c

Email Address

Name* Percentage*
%
Date of Birth (mm/dd/yyyy)* Relationship* Phone Number

Street Address City State Zip

Social Security Number/TIN Number*

Please distribute the proceeds “Per Stirpes” c

Email Address

Trust Name* Percentage*

%
Date of Trust (mm/dd/yyyy* Trust TIN*

Name of Trustee* Trustee Date of Birth (mm/dd/yyyy)* Phone Number

Street Address City State Zip

Trustee Social Security Number/TIN*

This is a Testamentary Trust c
Email Address

If you need more space or have attached additional sheets to your form, please check this box c. You may use additional blank pages completed with
beneficiary information, signed and dated on each sheet. Include the word “Attachment” and policy numbers on each additional sheet.

®
North American Company for Life and Health Insurance | New Business Processing Center: P.O. Box 5088, Sioux Falls, SD 57117 | Principal Office: West Des Moines, IA
Phone: 877-872-0757 | Fax: 877-208-6136 | NorthAmericanCompany.com
L-2402 Page 3 of 5 REV 5-23
 Section 4b: Contingent Beneficiary(ies)
*Fields are required for processing the Beneficiary Change request.
NOTE: Percentage (%) of proceeds for Contingent Beneficiary(ies) must equal 100%
Name* Percentage*
%
Date of Birth (mm/dd/yyyy)* Relationship* Phone Number

Street Address City State Zip

Social Security Number/TIN Number*

Please distribute the proceeds “Per Stirpes” c

Email Address

Name* Percentage*
%
Date of Birth (mm/dd/yyyy)* Relationship* Phone Number

Street Address City State Zip

Social Security Number/TIN Number*

Please distribute the proceeds “Per Stirpes” c

Email Address

Name* Percentage*
%
Date of Birth (mm/dd/yyyy)* Relationship* Phone Number

Street Address City State Zip

Social Security Number/TIN Number*

Please distribute the proceeds “Per Stirpes” c

Email Address

Trust Name* Percentage*

%
Date of Trust (mm/dd/yyyy* Trust TIN*

Name of Trustee* Trustee Date of Birth (mm/dd/yyyy)* Phone Number

Street Address City State Zip

Trustee Social Security Number/TIN*

This is a Testamentary Trust c
Email Address

If you need more space or have attached additional sheets to your form, please check this box c. You may use additional blank pages completed with
beneficiary information, signed and dated on each sheet. Include the word “Attachment” and policy numbers on each additional sheet.

®
North American Company for Life and Health Insurance | New Business Processing Center: P.O. Box 5088, Sioux Falls, SD 57117 | Principal Office: West Des Moines, IA
Phone: 877-872-0757 | Fax: 877-208-6136 | NorthAmericanCompany.com
L-2402 Page 4 of 5 REV 5-23
 Section 5: Signature of ALL Owners

The Trustee(s) agree to release, indemnify and hold harmless the Company, its officers, employees, agents/representatives, and affiliates from and against all
claims arising out of the sale or administration of the product to the Trust. The Trustee(s) certify that the product is suitable for the purposes of the trust and
does not impair the rights of the trust beneficiaries. The Trustee(s) acknowledge that the company has not provided any tax, legal or financial advice and is
not authorized to recommend or sell Trusts and any Trust recommendation has been provided by an independent tax, legal or financial advisor. The Company
will issue and administer the Contract based solely upon the representations made by the Trustee(s) and that any consequence of any error, inaccuracy, or
misunderstanding in interpreting the Trust will be borne solely by the Trustee(s).

If this transaction is subject to a community property interest, we strongly recommend that You obtain your spouse’s signature on the line below to document his/
her consent to this transaction. States that recognize community property interests in property held by married persons include Alaska, Arizona, California, Idaho,
Louisiana, Nevada, New Mexico, Texas, Washington, and Wisconsin.

You understand and agree that the Company may presume that no community property interest exists if You have not obtained your spouse’s signature below.
Further, You understand and agree that the Company has no duty to inquire further about any such
community property interest. As a result, You agree to indemnify and hold the Company harmless from any consequences relating to community property interests
and this transaction.

Please note that the term “spouse” includes domestic partner or other partner as permitted by civil union, domestic partnership or similar law.

I hereby revoke all previous beneficiary designations and request North American Company change the beneficiaries for the listed contract or policy.

CA Residents: For your protection, California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent information to
obtain or amend insurance or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Date Owner’s Signature*

Date Signature of Owner’s Spouse (Required if issue or resident state is AK, AZ, CA, ID, LA, NV, NM, TX, WA WI)

Date Signature of Joint Owner or Second Officer with Title

Date Signature of Disinterested Witness (Required in Massachusetts)

Date Signature of Irrevocable Beneficiary

If you are signing on behalf of the owner, as a legal representative, please print your name and provide your signature below. Check the box that applies to the
capacity in which you are signing. If you have not already done so, please provide the court documents to verify you are authorized to act on behalf of the owner
and have the authority to make such a change.

c Conservator c Guardian c Power of Attorney

Printed Name

Signature Date

Signature of Witness (Required Only in Massachusetts) Date

®
North American Company for Life and Health Insurance | New Business Processing Center: P.O. Box 5088, Sioux Falls, SD 57117 | Principal Office: West Des Moines, IA
Phone: 877-872-0757 | Fax: 877-208-6136 | NorthAmericanCompany.com
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