MAPS CONSTRUCTION
Guarantee ● Trust ● Life ● Insurance Beneficiary ● Designation
●
Company
Insured’s Name: __________________________________________________________
Last First Middle Initial
Start Date of Travel: ______________________________________________________
Month Day Year
Beneficiary: _____________________________________________________________ Beneficiary’s Relationship to Insured: ________________________________________ Policyholder: _______________________Assemblies of God______________________ Policy Number: ____________________246-018-001K___________________________ Signature of Insured: ______________________________________________________
Date of Signing: __________________________________________________________
*Note: one form required for each insured individual
Updated 04/25/06 lob
1
4/15/07 dms