BENEFICIARY CHANGE REQUEST by yaofenjin

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									                                                                               MONUMENTAL LIFE INSURANCE COMPANY
BENEFICIARY CHANGE REQUEST                                                  TRANSAMERICA FINANCIAL LIFE INSURANCE COMPANY
                                                                                 TRANSAMERICA LIFE INSURANCE COMPANY
NOTE: No beneficiary change is final. Any future beneficiary change
must be provided in writing and will cancel all prior beneficiary
designations for any amounts payable following the death of the                             AEGON companies
Claimant/Payee.                                                                    www.aegonstructuredsettlements.com
The Policy Owner must approve all beneficiary change requests.
Approval is subject to the terms of the settlement documents. If the
settlement documents do not give you this right, your change may
not be approved.
None of the Periodic Payments may be accelerated, deferred,            If more than one primary or contingent beneficiary is being
increased or decreased.                                                requested, please indicate the division of amounts payable
                                                                       (e.g., equally to the beneficiaries, 50%, etc.), otherwise
 _________________________________________________                     proceeds will be paid equally to all primary beneficiaries
 Policy Number                                                         surviving the Claimant/Payee. If all primary beneficiaries have
 _________________________________________________                     predeceased the Claimant/Payee, remaining guaranteed
 Claimant/Payee Name                                                   payments will be paid to the surviving contingent
 _________________________________________________                     beneficiaries. If there are no surviving beneficiaries, proceeds
 Claimant/Payee Resident – Street Address                              are payable to the Claimant/Payee’s Estate.
                                                                       If more space is needed, please list additional beneficiary
 _________________________________________________
 Claimant/Payee Resident – City, State and Zip                         information on a separate sheet and sign the request.

 _________________________________________________
 Claimant/Payee Telephone Number                                       Beneficiary Type (check one)
 _________________________________________________                      Primary      Contingent Beneficiary Percentage ______
 Claimant/Payee Social Security Number
                                                                       _________________________________________________
 _________________________________________________                     Beneficiary (full name)
 Claimant/Payee Signature*
                                                                       _________________________________________________
 _________________________________________________                     Beneficiary Resident – Street Address
 Joint Claimant/Payee Signature
                                                                       _________________________________________________
 _________________________________________________                     City, State and Zip         Beneficiary Phone Number
 Date
*Note: In states having community property laws,** the spouse of       _________________________________________________
the Claimant/Payee must also join and consent to naming a              Beneficiary Social Security Number Beneficiary Date of Birth
beneficiary other than the spouse.                                     _________________________________________________
                                                                       Relationship to Claimant/Payee
 _________________________________________________
 Notarized Signature of Spouse                    Date
    ** Arizona, California, Idaho, Louisiana, Nevada, New Mexico,      Beneficiary Type (check one)
    Texas, Washington, and Wisconsin.                                   Primary      Contingent Beneficiary Percentage ______
NOTARIZATION
                                                                       _________________________________________________
Please have a notary complete the following information.
                                                                       Beneficiary (full name)
 _________________________________________________                     _________________________________________________
 State of                       County of                              Beneficiary Resident – Street Address
 _________________________________________________                     _________________________________________________
 On (date)                                                             City, State and Zip         Beneficiary Phone Number
 _________________________________________________                     _________________________________________________
 Before me (name of notary)                                            Beneficiary Social Security Number Beneficiary Date of Birth
 _________________________________________________                     _________________________________________________
 Personally appeared (name of Payee)                                   Relationship to Claimant/Payee
 _________________________________________________
 Personally appeared (name of Joint Payee)
                                                                       Mailing and Overnight Address:
Personally known to me - OR - proved to me on the basis of
satisfactory evidence to be the person(s) whose name(s) is / are       AEGON Structured Settlements
subscribed to the within instrument and acknowledged to me that        Administrative Offices
he/she/they executed the same in his/her/their authorized              4333 Edgewood Road NE
capacity(ies), and that by his/her/their signature.                    Cedar Rapids, IA 52499
WITNESS my hand and official seal.
 _________________________________________________                     Phone: 1.800.866.0002
Signature of Notary                                                    Fax: 1.888.560.4860

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