Uniformed Services Benefit Association  

USBA MEMBER REQUEST FOR CHANGE OF NAME

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

Fill out the following form and send it to us along with a copy of a marriage certificate, divorce decree or other court or official document by:

Email to: usbamemb@usba.com
Fax to: (800) 368-7030
OR Mail to:
USBA
P.O. Box 25956
Overland Park, KS 66225-0956
If you prefer, call us TOLL-FREE at (800) 821-7912.


USBA NAME CHANGE FORM

USBA Member Number                                 

Group Policy Number   

USBA Certificate Number(s)  

Issued on the life of  

Change name FROM  

TO 

Email Address   



Signature

Date Signed