|
REQUEST FOR CHANGE OF NAME
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 of:
|
Change name FROM: |
|
|
TO: |
|
|
|
|
|
Date |
Signature (sign full name)
(Sign new name, if changed) |
|
Your e-mail address (so we can send confirmation): |
|
Mail your completed form to:
USBA
P.O. Box 25956
Overland Park, KS 66225-0956
Questions? Call 1-800-821-7912 |
