SBLI USA Life Insurance Company, Inc.
S.USA Life Insurance Company, Inc.
        
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Change Request

Owners may use this form to make a variety of changes to existing policies or certificates.

In order to process this change, we require proof of your signature (a copy of your Driver's License, Medicare Card, etc.)

For each request, please mail the completed forms to:

SBLI USA Life Insurance Company, Inc.
100 W. 33rd Street
New York, NY 10001
Attn: Customer Service Department

Name Change

a) Complete the appropriate portion of the Request for Change Form.

b) Include copies of a marriage license, court order, or other proof of change of name.

c) Sign with both the old and new name (e.g. Jane Smith, formerly known as Jane Adams).

d) The owner signs at the bottom and dates the form.

Date of Birth Change

a) Complete the appropriate portion of the Request for Change Form.

b) Include a notarized copy of the insured's birth certificate or other legal documentation showing correct age or date of birth.

c) The owner signs at the bottom and dates the form.

Automatic Premium Loan Request

If a premium is not paid within the grace period, an Automatic Premium Loan automatically pays all premiums for the rest of the policy year, provided the loan value is sufficient.

a) After issue, the owner may select this benefit by requesting it in writing in the appropriate section of the Request for Change Form.

b) Sign and date the form.

Dividend Option Change

a) Select Dividend Option Change(s) on the Request for Change Form.

b) Sign and date the form.



Address Change

a) Complete the appropriate section of the Request for Change Form. Other written notice is also sufficient for address changes.

b) Sign and date the form.

Premium Mode Change

a) Choose the mode of payment you would like, and check the box in the appropriate section of the Request for Change Form.

b) Sign and date the form.



Requests will be processed upon receipt of the signed documents. We will return an acknowledged copy for your records. If for any reason the mode is not available for your policy, we will inform you. To change a beneficiary, complete the Change of Beneficiary form.
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