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

Current Phone Number In Use This will be the number we have on your profile

Area Code

Phone Number

4

Additional Phone NumberThis will be the number we add to your profile

Area Code

Phone Number

5

Email

example@example.com

6

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/addition of information on my policy by submitting this completed online request.

7

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

Accept

8

Signature

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