AMERICAN-AMICABLE LIFE INSURANCE COMPANY OF TEXAS
IA AMERICAN LIFE INSURANCE COMPANY
OCCIDENTAL LIFE INSURANCE COMPANY OF NORTH CAROLINA
PIONEER AMERICAN INSURANCE COMPANY
PIONEER SECURITY LIFE INSURANCE COMPANY
Client Experience Department • PO Box 2549, Waco Texas 76702-2549 • Fax: 254-297-2105 • Email: [email protected]
BENEFICIARY CHANGE INSTRUCTIONS AND HELPFUL HINTS
Please follow these instructions for completing the form:
1. Please use dark ink and print all information except signatures.
2. You must provide all information requested. Complete and accurate information will help expedite the
beneciary change request.
3. If there are multiple primary or contingent beneciaries, they will share equally in the policy proceeds unless
you indicate a percentage for each named beneciary in the area indicated. Please note that the total of
all percentages for each beneciary category must equal 100%. Do not use dollar amounts.
4. If you use liquid paper or scratch out information, those changes must be initialed by the policy owner.
5. The current policy owner must complete and sign the bottom portion of the form. The witness to the policy
owner’s signature must be a non-relative and not named as the new beneciary.
6. If additional room is needed, please use a separate sheet of paper. Each page must include: a) the policy
number and name of the insured, b) the information requested on the form, c) signature of the Owner(s)
with the date signed and d) the signature of a witness. If you wish, you can make copies of this form and
number them.
7. If the new beneciary is a trust, the trust name and date must be included as the name information in the
appropriate box on the form.
8. If new beneciary is NOT a family member, document must be notarized or it will not be processed.
HELPFUL HINTS FOR NAMING A BENEFICIARY
A family member or members are the most common type of beneciary designation. Designating a family
member as beneciary is usually not a problem as long as the person is not a minor.
Example: Jane Doe, spouse Example: Jane Doe, spouse - 50%
Fred Doe, son - 50%
Children should not be named as beneciary unless there is a trustee named to handle the claim transaction.
If there is no trustee, the insurance company must determine who has the legal authority to accept payment on
behalf of the minor child or children which may delay payment of the proceeds.
Example: Jane and Fred Smith, children, with John Doe as trustee if said children are minors. If you decide to
name your children, please include the name, address, social security # and date of birth for each child.
It is always a good idea to name a contingent beneciary as the primary beneciary may predecease the insured
and if no contingent beneciary is named, the proceeds would be paid in accordance with the policy provisions.
If a creditor is to be the beneciary, the form should indicate the amount that is to go to the creditor.
Example: XYZ Bank as its interest may appear with the balance payable to Jane Doe, spouse.
If you name a funeral home as the primary beneciary, please indicate “as their interest appears” and name a
contingent beneciary to receive any proceeds not paid to the funeral home.
If you have any questions regarding a beneciary designation, please visit our website and chat with
us online using the Live Chat tool available in your account portal or email us at [email protected].
BEFORE RETURNING THIS FORM, HAVE YOU:
• completed Section A and provided us with complete Policyowner information?
• provided us with complete Primary beneciary information in Section B?
• provided us with complete Contingent beneciary information in Section C?
• completed Section D by providing us with all appropriate signatures and dates?
AMERICAN-AMICABLE
GROUP OF COMPANIES
6990(4/24)
Beneficiary Change Request
Beneficiary change requests can only be made during the lifetime of the insured. Upon the Insurer’s receipt of this completed form, the Beneficiary
change will be effective as of the date it was signed by the Policyowner. However, the change will be subject to any payment that the Insurer may
have made or actions it may have taken prior to receipt of the completed form. The Company may acknowledge receipt of this requested change
but does not assume responsibility for its validity or legal effect or the rights and liabilities of any person.
This request supersedes and revokes all previous primary and contingent beneficiary designations.
Important Instructions
1. If you name multiple beneficiaries and don’t want the proceeds paid in equal shares, please indicate a percentage for each beneficiary in the
appropriate box. The total of all percentages in each section must equal 100%. A dollar amount cannot be used.
2. If additional space is needed, please attach a separate sheet which includes: a) the policy number and name of insured; b) the information
requested in the box below; c) signature of Owner(s) along with the date; and d) the signature of a Witness.
3. If new beneficiary is a trust, the trust name and date must be included as the name in the information box below.
4. If new beneficiary is NOT a family member, document must be notarized.
Please use dark ink and print all information except signatures.
Section A - Policy information (you must complete this section)
Policy Number Insured’s Name
Policyowner’s Name Policyowner’s Social Security No. Policyowner’s Date of Birth
Address City State Zip Code Phone Number
Section B - Primary beneficiary information
Primary – The undersigned hereby requests that all previous primary beneficiary designations and settlement options elected be revoked
and makes the following designations:
Name Social Security Number Date of Birth Relationship to Insured Percentage
Address City State Zip Code Phone Number
Name Social Security Number Date of Birth Relationship to Insured Percentage
Address City State Zip Code Phone Number
Name Social Security Number Date of Birth Relationship to Insured Percentage
Address City State Zip Code Phone Number
Section C - Contingent beneficiary information
Contingent (secondary) – Receives benefits ONLY if no Primary Beneficiary survives the insured. The undersigned hereby requests that
all previous contingent beneficiary designations and settlement options elected be revoked and makes the following designations:
Name Social Security Number Date of Birth Relationship to Insured Percentage
Address City State Zip Code Phone Number
Name Social Security Number Date of Birth Relationship to Insured Percentage
Address City State Zip Code Phone Number
Section D - Signatures (you must complete this section)
Policyowner Signature (with title if applicable) Policyowner’s Telephone Number Date Signed (mm/dd/yyyy)
Co-owner Signature (with title if applicable) or Second Officer with title (if corporate-owned) Date Signed (mm/dd/yyyy)
Witness Signature (cannot be a relative or designated Beneficiary) Name of Witness (Please Print) Date Signed (mm/dd/yyyy)
Have you...
• completed Section A and provided us with complete Policyowner information?
• provided us with complete Primary beneficiary information in Section B?
• provided us with complete Contingent beneficiary information in Section C?
• completed Section D by providing us with all appropriate signatures and dates?
IF BENEFICIARY IS NOT A FAMILY MEMBER, THIS FORM MUST
BE NOTARIZED OR IT WILL NOT BE PROCESSED.
Mail to:
Client Experience Department
P.O. Box 2549
Waco, TX 76702-2549
Contact Information:
Fax: 1-254-297-2105
Notary Public:
