CHANGE OF BENEFICIARY Date: ____________________ To: _____________________ Notice is hereby given to you to change the beneficiary on Policy Number __________ of _________________________________________________. The policy was issued by ______________________________________________ (hereinafter "company"). Subject to the provisions attached and marked as Exhibit A, the beneficiary is to be changed from _________________________________, of _____________________, to _________________________________, of ______________________________. This request for change of beneficiary shall take effect as of the day it is signed, accepted, and recorded at the home office of the company. Any previous selection of a beneficiary is hereby revoked. Signed: ________________________