Form Ben-Cskc - Beneficiary Change Form Page 2
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4Monumental Life Insurance Company
Beneficiary
Stonebridge Life Insurance Company
Change Form
Transamerica Life Insurance Company
Western Reserve Life Assurance Company of Ohio
Fax Number 1-800-297-9120
Administrative Office located at: 4333 Edgewood Rd. NE, Cedar Rapids, IA 52499
Section 1:
Policy Information
P
olicy Number(s)_____________________________________ Owner_________________________________________
Owner Address ______________________________________City/State/Zip ____________________________________
Insured ____________________________________________ Insured Phone No. ________________________________
Insured Social Security No.______________________ Insured Birth Date _______________________________________
Insured Address ______________________________________City/State/Zip ____________________________________
Section 2:
Primary Beneficiary Information (If completed, revokes prior designations)
Primary beneficiary: Receives any proceeds payable at the insured’s death.
The policy’s death benefit will be paid to multiple beneficiaries in equal shares unless otherwise indicated.
If additional space is needed, please write “See attached” on this form and attach an additional page. Please sign and
date this form as well as the additional page(s).
Primary Beneficiary(ies)
If this section is left blank, the primary beneficiary will remain as currently listed on policy.
Name _________________________________________________________________________________________
share equally
Relationship _________________________________________________ Birth or Trust Date________________
OR
Address ______________________________________________________________________________________
City/State/Zip _________________________________________________________________________________
________%
Phone Number___________________________________ SSN or Tax ID Number ________________________
Name _________________________________________________________________________________________
share equally
Relationship _________________________________________________ Birth or Trust Date________________
OR
Address ______________________________________________________________________________________
City/State/Zip _________________________________________________________________________________
________%
Phone Number___________________________________ SSN or Tax ID Number ________________________
Name _________________________________________________________________________________________
share equally
Relationship _________________________________________________ Birth or Trust Date________________
OR
Address ______________________________________________________________________________________
City/State/Zip _________________________________________________________________________________
________%
Phone Number___________________________________ SSN or Tax ID Number ________________________
Name _________________________________________________________________________________________
share equally
Relationship _________________________________________________ Birth or Trust Date________________
OR
Address ______________________________________________________________________________________
City/State/Zip _________________________________________________________________________________
________%
Phone Number___________________________________ SSN or Tax ID Number ________________________
Primary Beneficiary Percentage Total (must equal 100%)
_________%
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BEN‐CSKC 02/14
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