Uniformed Services Benefit Association  


This form may help if you’re away from home and you want your spouse or parents to handle some of your business transactions with us, most of your paperwork is handled by your Financial Advisor or your attorney, or you’d like to have your spouse call us on occasion for information. Without your signed Authorization, we do not release information to another person, not even your spouse. But if it suits your needs to allow this, just complete the Authorization below, have your signature notarized, and return it to us.

Your signature on this form does NOT allow another person to change your USBA insurance or beneficiary arrangement in any way. It simply permits us to release information to that person if requested. You may revoke this authorization at any timeby sending a signed statement to that effect. You are not required to complete this form at all. It is an option for those members who choose to do so. If you do send the form to us, we’ll keep it in your file for reference. You may keep this form with your important papers, completing and sending it to us anytime.

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

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

AUTHORIZATION: To Uniformed Services Benefit Association

You may furnish the following individual any information or forms s/he requests with reference to my certificate(s) with your Association.

Full Name: Relationship:

Check One:

    This authorization expires 12 mos. from date signed or date received, whichever is earlier.
    This authorization remains in effect until revoked by me in writing.

Signature of Member: Date:
Print Name: Your USBA Membership #:
Your E-mail Address:

NOTE: This form must be notarized to be valid.

Notary Public:

Sworn and Subscribed this day of 20