Uniformed Services Benefit Association  

USBA MEMBERS REQUEST FOR CHANGE OF NAME

When you change your name, use this form to keep your name current on USBA records.

Please print this page, fill it out and mail to:

USBA
P.O. Box 25956
Overland Park, KS 66225-0956
If you prefer, call us TOLL-FREE at (800) 821-7912 or send us an e-mail.


For USBA Group Life Insurance Coverage

Group Policy Number:  
USBA Certificate(s):  
Issued on the life of:  

 

New York Life Insurance Company is hereby requested
to record the following change of name:

Change name FROM:
TO:  
   
Date
Signature (sign full name) – Sign new name, if changed.
Your e-mail address so we can send confirmation: