NATIONAL INCOME LIFE INSURANCE COMPANY
PO Box 5009 Syracuse , NY 13220
POLICY SERVICE REQUEST
BENEFICIARY CHANGE
- Print this form from your computer. After you fill out the form mail it (with an ORIGINAL signature) to the following address:
National Income Life Insurance Company
PO Box 5009
Syracuse , NY 13220
| POLICY NUMBER |
INSURED |
OWNER |
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Primary Beneficiary:
| Unless otherwise specified, proceeds to be paid in equal shares to the survivor(s) |
Address |
Relationship |
Birthdate |
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Contingent Beneficiary – to be paid if no surviving Primary Beneficiary at the time of death:
| Unless otherwise specified, proceeds to be paid in equal shares to the survivor(s) |
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Birthdate |
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________________ ___________________________________________________
Date Signature of Owner
** IT IS NOT NECESSARY TO SEND US YOUR POLICY **
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