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TRANSAMERICA PREMIER LIFE INSURANCE COMPANY 2700 West Plano Parkway Plano TX 75075-8200 www. insuranceservicenow. com BENEFICIARY CHANGE REQUEST Policy/Certificate Number On the Life of Date In order to change the beneficiary on your policy/certificate please provide the information requested below make a copy of this form for your records and return the completed form* I the undersigned policyowner do hereby request the Company to revoke all prior beneficiary designations and optional methods of settlement if any and change the beneficiary of said policy as follows Primary Beneficiary or Beneficiaries if living Name Relationship Street Address City State Zip Otherwise to Contingent Beneficiary or Beneficiaries The provisions in this Beneficiary Change take precedence over any printed provisions in the policy which establish a beneficiary. Unless otherwise provided above the proceeds shall be paid in a lump sum* When more than one Primary Beneficiary is named payment shall be made share and share alike to survivors or survivor unless otherwise provided above. This also applies when more than one Contingent Beneficiary is named* If no beneficiary survives the Insured the policy proceeds will be paid to the Insured s Estate. I hereby request and by recording this instrument the Company hereby agrees that any provision of the policy requiring the policy to be submitted to the Company for endorsement of change of beneficiary thereon be waived* The designation of the new beneficiary or beneficiaries shall become effective as of the date of the request for such change provided however the request must be first received and recorded by the Company. Any payment made by the Company prior to such receipt and recording shall constitute proper whole and absolute payment and shall discharge the Company from liability. If a trust or trustee beneficiary is named the Company may make payment to the trust or the trustee without having to determine whether a trust is in effect and shall not be required to look after the application of the proceeds in the hands of the trust or the trustee. I understand that this Beneficiary Change after it has been recorded by the Company will take effect as of the date I signed the request. I further understand and agree that any payment made prior to the receipt and recording of this Beneficiary Change will not be affected* Signature of Primary Insured CSZB Signature of Spouse INET. com BENEFICIARY CHANGE REQUEST Policy/Certificate Number On the Life of Date In order to change the beneficiary on your policy/certificate please provide the information requested below make a copy of this form for your records and return the completed form* I the undersigned policyowner do hereby request the Company to revoke all prior beneficiary designations and optional methods of settlement if any and change the beneficiary of said policy as follows Primary Beneficiary or Beneficiaries if living Name Relationship Street Address City State Zip Otherwise to Contingent Beneficiary or Beneficiaries The provisions in this Beneficiary Change take precedence over any printed provisions in the policy which establish a beneficiary. Unless otherwise provided above the proceeds shall be paid in a lump sum* When more than one Primary Beneficiary is named payment shall be made share and share alike to survivors or survivor unless otherwise provided above.