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Life Insurance

Form

Use this form to...

Notes

Request to Change  Beneficiary (Insurance)

Change the beneficiary of your certificate

All signatures must be notarized

Request to Change Name of Insured

Change the name of the insured on your certificate

Must provide legal proof of name change as noted on the form

Request to Change Owner

Change the owner of your certificate

Must provide legal proof of name change as noted on the form

Operation/Dismemberment Claim

Request and document Operation and/or Dismemberment benefit claims

Must be completed and signed by the Physician or Surgeon, or accompanied by billing information to support claim

Application for Cash Surrender

Request cash surrender of life certificate

Must be signed by the insured and payer/owner

 

 

LOCATION

11265 Decatur St.

Suite 100

Westminster, CO 80234

 

 

MAIL

PO Box 351920

Westminster, CO 80035-1920

 

 

PHONE

(800) 451-7528

(303) 451-1494

FAX

(303) 451-5112

 

 

EMAIL

info@wsalife.com

WSA Fraternal Life is not licensed in all states. Nothing contained herein should be construed as a solicitation for insurance or annuity products in any state in which WSA Fraternal Life is not licensed.

Click here for a compete list of states in which WSA Fraternal Life is licensed.

Participation in any WSA Fraternal Life event constitutes agreement to the Terms and Conditions for Participation in WSA Events

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