NATIONAL INCOME LIFE INSURANCE COMPANY

NATIONAL INCOME LIFE INSURANCE COMPANY

POLICY SERVICE REQUEST
BENEFICIARY CHANGE

Print this form from your internet browser screen. After you fill out the form, mail it (with an ORIGINAL signature) to the following address:

National Income Life Insurance Company
c/o National Income Life Service Center
PO Box 2608
Waco, TX 76797

Primary Beneficiary:

Unless otherwise specified, proceeds to be paid in equal shares to the survivor(s)	Address	Relationship	Birthdate

Contingent Beneficiary – to be paid if no surviving Primary Beneficiary at the time of death:

Unless otherwise specified, proceeds to be paid in equal shares to the survivor(s)	Address	Relationship	Birthdate

COMMENTS:

________________ ___________________________________________________
Date Signature of Owner

** IT IS NOT NECESSARY TO SEND US YOUR POLICY **