Are you sure you want to change the beneficiary?

1

Your Name and SurnamePolicy holder (main member) name and surname

First Name

Last Name

2

ID / Passport NumberPlease provide your full ID or Passport Number

3

Phone Number

Area Code

Phone Number

4

New Beneficiary NameProvide your new beneficiary's Name and Surname

First Name

Last Name

5

New Beneficiary ID / Passport NumberPlease provide the new beneficiary's full ID or Passport Number

6

New Beneficiary Contact Number

Area Code

Phone Number

7

Beneficiary relationship to main memberPlease confirm the relationship of the beneficiary to yourself

8

Declaration:

I hereby declare that the above-mentioned information is true and correct to the best of my knowledge. I also declare that I am the main member on the Lifewize policy for which this change is being requested. I hereby consent to the change of beneficiary on my policy by submitting this completed online request.

9

I have read the declaration and accept* This field is required.

Accept

10

Signature

Powered by Jotform SignClear