BENEFICIARY CHANGE REQUEST

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1 Poliy/Certifiate Number(s) BENEFICIARY CHANGE REQUEST *L2402* *L2402* Setion 1: Insured First Name Middle Name Last Name Permanent Address: City, State, Zip Code Please hek if you would like the address listed to be the address of reord for the poliy. Phone Number of Birth Soial Seurity Number/Tax Identifiation Number (TIN) The poliy proeeds payable upon the death of the insured for eah poliy listed above will be paid to the benefiiaries named herein. Setion 2: Owner (If different than Insured) If there are multiple owners, please designate one address for all poliy orrespondene to be mailed to sine our administrative systems will only allow one address for mailing. Please note: If you do not indiate an address for mailing, the first owner listed will beome the nominee owner and reeive all orrespondene. First Name Middle Name Last Name Permanent Address: City, State, Zip Code Please hek if you would like the address listed to be the address of reord for the poliy. Phone Number of Birth Soial Seurity Number/Tax Identifiation Number (TIN) Setion 3: General Provisions Please omplete the form(s) in their entirety to avoid delays in proessing. Please use perentages in your designation - frations and dollar amounts are not aepted. Designations must equal 100. All benefiiary hanges MUST inlude the designation of a Primary Benefiiary. Even if you only want to hange the Contingent Benefiiary, you must restate the Primary Benefiiary. To distribute proeeds per stirpes please hek the box. Per Stirpes is a ommon way of distributing proeeds where if one or more of your benefiiaries has died, his or her hildren share equally in his or her share of the proeeds (also known as Right of Representation). If per stirpes is seleted please attah a separate page listing the names, soial seurity numbers and date of birth for all hildren. Continued on Page 2 North Amerian Company Administrative Offie: P. O. Box 5088, Sioux Falls, SD Prinipal Offie: West Des Moines, IA Phone: (877) Fax: (877) Page 1 of 7

2 Contingent Benefiiaries will reeive death benefit proeeds in the event that the Primary Benefiiary predeeases the insured and if the primary designation did not inlude per stirpes. If you need additional spae or wish to designate more than four benefiiaries, attah another sheet marked Attahment. Eah attahment must ontain poliy number(s) and be signed and dated. If a Trust is named benefiiary, omplete the Certifiation of Trust in setion 6. The Company is not required to know or researh the terms of the Trust. Payment to the named trust will fully disharge all liability of the Company to the extent of suh payment. If the owner is a Company or Plan, please provide a urrent list of those authorized to sign on the ompany s behalf. The form must be signed by two authorized representatives (signors). If a legal representative signs for the Owner, supporting legal doumentation must aompany the form. Any payment to a minor benefiiary will be held with the Company until the state s age of majority or until Legal Guardianship of the minor s Estate is established or unless otherwise permitted by law. If the Insured s Estate is seleted as Primary Benefiiary, a Contingent Benefiiary does not apply. If the owner resides in Massahusetts, the owner s signature must be witnessed by a disinterested person over 18 who is not being named benefiiary. Page 2 of 7

3 BENEFICIARY CHANGE REQUEST Setion 4A: Primary Benefiiary(ies) * fields are required for proessing the Benefiiary Change request. If you need more spae or have attahed additional sheets to your form, please hek this box. You may use additional blank pages ompleted with benefiiary information, signed and dated on eah sheet. Inlude the word Attahment and poliy numbers on eah additional sheet. Page 3 of 7

4 BENEFICIARY CHANGE REQUEST Setion 4B: Contingent Benefiiary(ies) * fields are required for proessing the Benefiiary Change request. If you need more spae or have attahed additional sheets to your form, please hek this box. You may use additional blank pages ompleted with benefiiary information, signed and dated on eah sheet. Inlude the word Attahment and poliy numbers on eah additional sheet. Page 4 of 7

5 Setion 5: Signature of ALL Owners If this transation is subjet to a ommunity property interest, we strongly reommend that You obtain your spouse s signature on the line below to doument his/her onsent to this transation. States that reognize ommunity property interests in property held by married persons inlude Alaska, Arizona, California, Idaho, Louisiana, Nevada, New Mexio, Texas, Washington, and Wisonsin. You understand and agree that the Company may presume that no ommunity property interest exists if You have not obtained your spouse s signature below. Further, You understand and agree that the Company has no duty to inquire further about any suh ommunity property interest. As a result, You agree to indemnify and hold the Company harmless from any onsequenes relating to ommunity property interests and this transation. Please note that the term spouse inludes domesti partner or other partner as permitted by ivil union, domesti partnership or similar law. I hereby revoke all previous benefiiary designations and request North Amerian Company hange the benefiiaries for the listed ontrat or poliy. Owner s Signature* Signature of Owner s Spouse (Required if issue or resident state is AK, AZ, CA, ID, LA, NV, NM, TX, WA WI) Signature of Joint Owner or Seond Offier with Title Signature of Disinterested Witness (Required in Massahusetts) If you are signing on behalf of the owner, as a legal representative, please print your name and provide your signature below. Chek the box that applies to the apaity in whih you are signing. If you have not already done so, please provide the ourt douments to verify you are authorized to at on behalf of the owner and have the authority to make suh a hange. Conservator Guardian Power of Attorney Printed Name Signature Signature of Witness (Required Only in Massahusetts) Page 5 of 7

6 Setion 6: Trust Agreement CERTIFICATION OF TRUST AGREEMENT Please omplete using information from the Trust doument Poliy No(s): *Please state pending if this form is being submitted with a new appliation. Name of Insured(s): First Name M.I. Last Name First Name M.I. Last Name Full Name of Trust Trust Effetive Trust Identifiation Number/Tax ID Number Whih state law governs this Trust? Preparer of Trust Preparer s Telephone Number Preparer s Address Street City State Zip If Trust is benefiiary, is it a testamentary trust? Yes No If yes, please sign here (poliy owner) and return the form (form is omplete). If no, please omplete the remainder of the form. Name of Grantor(s)/Settlor(s): First Name M.I. Last Name First Name M.I. Last Name Name/Address of Trustee(s): *Please attah additional pages if insuffiient spae has been provided. Trustee(s) of Birth: Trustee(s) SSN: Trustee(s) Telephone #: Name/Address of Suessor Trustee(s): *Please attah additional pages if insuffiient spae has been provided. 1. The above referened Trust Agreement (the Trust ) requires that: (Please mark the appropriate box.) all Trustees a majority of Trustees any Trustee Trust only has one Trustee must sign douments pertaining to the above-referened Poliy whih require a signature. 2. The insurane agent or any person affiliated with the insurane agent is not a benefiiary of the above referened trust. Agree Disagree * If marked disagree, please attah an explanation of why your agent or person affiliated with your agent is named as a benefiiary of the trust. Note: Under the laws of most states, an agent is restrited in, or prohibited from, having a benefiial interest in a ontrat sold by that agent, unless that agent is a family member, or has a reognized insurable interest. Additionally, our Company poliy prohibits our agents from serving in any apaity that may be onstrued as reating a diret or indiret onflit of interest with regard to a ontrat or ontrats for whih they are or have been the agent(s) of reord. 3. The relationship of the Trust Benefiiary(ies) to the Insured is: Spouse Children Grandhildren Other Please explain. 4. Was the Trust validly exeuted, and is it in full fore and effet? Yes No Please be advised that the Insurer reserves the right to request and reeive a opy of the Trust douments if it determines that it is neessary to do so. Before the Insurer pays proeeds at the death of the Owner/Insured of the Poliy(s) it may also require proof that the Trust is then in full fore and effet. Page 6 of 7

7 Delaration by Trustee(s) The Trustee(s) states and agrees that if the Trust is named as owner, it is authorized under the terms of the Trust to purhase and hold insurane; that if the Trust is named as benefiiary of the Poliy(s), it is authorized to reeive insurane proeeds. The Trustee represents that they have determined the suitability of the Poliy for the Trust. The Trustee agrees that the Insurer s sole obligation is to perform under the terms of the Poliy(s). The Trustee also agrees that the Insurer may rely on the signature(s) of the Trustee(s) on behalf of the Trust in the same regard as if they were the atual owner or benefiiary of the Poliy(s); the Insurer may rely solely on this Certifiation as well as the statements and representations made in the assoiated appliation, as a basis for issuing and/or performing obligations of the above-referened Poliy and to determine the trust is in effet and the information provided is aurate; the Insurer has no obligation to investigate the terms of the Trust or the authority of the Trustee(s) and will not be aountable for knowledge about the terms of the Trust beyond this Certifiation; the Insurer expressly denies responsibility regarding the use and appliations of any payments to the Trustee(s); the Insurer has no obligation to determine the Poliy s onformane to inome distribution requirements of the Trust agreement. The Trustee(s) delares they have had an opportunity to onsult with their own independent legal, tax and trust advisors onerning the appropriateness of the Poliy(s) for the Trust and they have the authority to exeute this Agreement and bind the Trust to the terms therein. As Trustee(s), and on behalf of the Trust, agree to hold the Insurer and its agents, employees, and other representatives harmless from any ation the Insurer takes at the diretion of the Trustee(s); unless suh hold harmless is not permitted by appliable law. The Trustee(s) delares, solely in its apaity as trustee and not individually and on behalf of the Trust, that eah and every Trustee and suessor Trustee are bound by this delaration. If is further understood that the Insurer may rely upon the diretion of the named Trustee(s) and any named suessor Trustee(s) until the Insurer reeives written notifiation at its Administrative Offie, of a hange of Trustee. The Trustee(s) agrees to notify the Insurer within a reasonable time after suh a hange ours. The Trustee further aknowledges and agrees that: The Trustee further aknowledges and agrees that: (a) Neither the Insurer or agents are authorized by the Company to reommend or sell Trusts while ating in their apaity as an agent for the Company and that any trust reommendation should be provided by a qualified advisor; (b) neither the Company nor any of its agents, employees or representatives are authorized to give tax or legal advie; () the Trustee(s) has not relied upon any representation or advie of any of the insurer s agents, employees or representatives with respet to the terms of validity of the Trust or the utilization of the Trust as the owner and/or benefiiary of this Poliy; and (d) the purhase of this Poliy is not required in onjuntion with the establishment of the Trust and that any fees, osts and/or expenses assoiated with the establishment of the Trust are independent of any premium paid for the purhase of this Poliy. Note: The number of Trustees indiated in Question 1 must sign below. By: (Trustee Signature) By: Trustee Signature By: (Trustee Signature) By: Trustee Signature For Corporate Trustees: Title/Capaity of Signatory: Trustee Name: (Please Print or type) Trustee Signature: X : Page 7 of 7

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