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review their beneficiary designations - AccessAllstate

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Lincoln Benefit Life Company<br />

THIS FORM NOT TO BE USED WITH SECTION 401 OR 403(b) CONTRACTS P.O. Box 80469, Lincoln, NE 68501-0469<br />

TEL: 1-800-525-9287<br />

Use ball point pen when completing form<br />

FAX: (Annuities) 1-877-525-2689 (Life) 1-866-525-5433<br />

STEP 1 - CONTRACT/POLICY INFORMATION (ALL FIELDS MUST BE COMPLETED). Only one policy number<br />

and Insured/Annuitant per change form. Submit a separate change of <strong>beneficiary</strong> form for each policy.<br />

Owner’s Name Owner’s SSN/TIN Contract/Policy #<br />

Joint Owner’s Name (if applicable)<br />

Insured or Annuitant’s Name<br />

Name and Date of Trust<br />

Name of Current Trustee<br />

Trust Tax ID Number<br />

Joint Owner’s SSN/TIN<br />

Insured or Annuitant’s SSN/TIN<br />

STEP 2 - PRIMARY BENEFICIARY (IES) – If more than 2 Primary Beneficiaries, please use a separate sheet of paper and<br />

attach to this form. Percentages must add up to 100%.<br />

If the Contract Owner is the TRUST then the Beneficiary should also be the TRUST.<br />

A. Individual, Corporation or Estate<br />

Name of Primary Beneficiary #1<br />

Name of Primary Beneficiary #2<br />

NOTE: Please use WHOLE Percentages ONLY<br />

NOTE: Please use WHOLE Percentages ONLY<br />

Street Address<br />

Street Address<br />

City/State/Zip<br />

City/State/Zip<br />

SSN/TIN<br />

Date of Birth (MM/DD/YYYY) SSN/TIN<br />

Date of Birth (MM/DD/YYYY)<br />

Relationship<br />

Relationship<br />

B. Trust as Primary Beneficiary (NOT Under Last Will)<br />

Street Address City State Zip<br />

C. Trust as Primary Beneficiary (Trust Within Last Will)<br />

To the trustee of the trust created pursuant to the Last Will and Testament of ____________________________ as admitted<br />

Name<br />

to probate provided the trustee submits a written claim within six months of the death of the person that triggered payment<br />

under the policy. If no such claim is made by the trustee, the proceeds shall be paid to _______________________________.<br />

Name<br />

STEP 3 - CONTINGENT BENEFICIARY(IES) – If more than 2 Contingent Beneficiaries, please use a separate sheet<br />

of paper and attach to this form. Percentages must add up to 100%.<br />

Name of Contingent Beneficiary #1<br />

Name of Contingent Beneficiary #2<br />

NOTE: Please use WHOLE Percentages ONLY<br />

NOTE: Please use WHOLE Percentages ONLY<br />

Street Address<br />

Street Address<br />

City/State/Zip<br />

City/State/Zip<br />

SSN/TIN<br />

Date of Birth (MM/DD/YYYY) SSN/TIN<br />

Date of Birth (MM/DD/YYYY)<br />

Relationship<br />

Relationship<br />

FIC77LBL-2 Page 4 of 5 (08/09)<br />

Review your beneficiaries.<br />

Name and relationship<br />

of <strong>beneficiary</strong><br />

Are they currently a<br />

<strong>beneficiary</strong>? How much<br />

will they receive?<br />

What do you hope<br />

this person will do<br />

with the proceeds? 3<br />

Is action needed?<br />

Example:<br />

Connie Johnson<br />

Wife of 20 years<br />

Yes<br />

$400,000<br />

Pay off all debts and<br />

put the kids through<br />

college, without having<br />

to work full time.<br />

Yes. Based on our<br />

current expenses, I<br />

need to increase her<br />

share of the proceeds<br />

to $550,000.<br />

If you answered anything other than 'No' in this column, then action is needed.<br />

Make an appointment with your financial professional today to<br />

discuss how to help protect your loved ones in the future.<br />

REQUEST FOR<br />

CHANGE OF BENEFICIARY (PAYEE)<br />

❑ Equally OR ❑ Percentage %<br />

❑ Equally OR ❑ Percentage %<br />

Use our Change of Beneficiary form (FIC77LBL)<br />

to update the beneficiaries on your LBL policies.<br />

❑ Equally OR ❑ Percentage %<br />

❑ Equally OR ❑ Percentage %<br />

3 Beneficiaries may use proceeds for any purpose and are under no contractual obligation to carry out the owner's desires.<br />

LBL8060

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