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Name Change Form

This document is a name change request form from Symetra Life Insurance Company. It requests the insured's name before and after the name change, as well as the reason for the name change such as marriage, divorce, or corporation name change. It requires documentation supporting the name change such as a marriage certificate, divorce decree, or corporate resolution. The form must be signed by the owner, joint owner, spouse where required, and irrevocable beneficiary with instructions provided for each party.

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Jeff Wiseman
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205 views

Name Change Form

This document is a name change request form from Symetra Life Insurance Company. It requests the insured's name before and after the name change, as well as the reason for the name change such as marriage, divorce, or corporation name change. It requires documentation supporting the name change such as a marriage certificate, divorce decree, or corporate resolution. The form must be signed by the owner, joint owner, spouse where required, and irrevocable beneficiary with instructions provided for each party.

Uploaded by

Jeff Wiseman
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Symetra Life Insurance Company

777 108th Avenue NE, Suite 1200 | Bellevue, WA 98004-5135


Mailing Address: PO Box 34690 | Seattle, WA 98124-1690
Phone 1-800-796-3872 | TTY/TDD 1-800-833-6388

NAME CHANGE REQUEST


Insured name(s)

Insured DOB(s)

Owner name(s) (if other than insured)

Policy number

Owners mailing address

City

Home phone

Mobile phone

State

Work phone

Zip code

Email address

To complete the name change, please complete the section below including the name before and after the name change.
Supporting documentation must be provided. More detailed instructions can be found on page 2 of this form.

Please change the name from:


to:

Print name - before name change

Previous signature - before name change

Print name - after name change

Current signature - after name change

Reason for name change:


Marriage Divorce -

Please attach a photocopy of the marriage certificate


Please attach a photocopy of the divorce decree

Corporation Name Change -

Please attach a certified copy of the corporate resolution/merger


documentation authorizing the change

Other -

Please specify ____________________________________________________________________

Required documents:
A photocopy of both Drivers License and Social Security Card, OR
A photocopy of both Drivers License and Passport, OR
Court Order
Owners signature

(If the policy owners name is being changed, please have the new signature notarized. If the signature is not notarized, a notarized
signature will be required for any future changes. If policy is owned by a corporation, please include corporate resolution.)

Owners signature or Corporate Officer with Title (if owned by Corporation)

Date

Joint Owners signature or Corporate Officer with Title


(if owned by Corporation)

Date

Spouses signature (required in AK, AZ, CA, ID, LA, NV, NM, TX, WA, WI)
Spouses signature

Date

Signature of Witness (Required in MA)

Date

Irrevocable Beneficiary signature if any (Notary required)

Date

Printed name of Witness (Required in MA)

Date

Notary: On this day personally appeared before me________________________________________________


who executed this form and acknowledged that he or she (or they) signed the same as his or her (or their) free
and voluntary act and deed for the uses and purposes therein mentioned.

Given under my hand and official seal this _______ day of _________________.
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Notary Stamp Here

Notary signature

Please see other side for instructions

Name Change Instructions


Who can request a name change?
Any party whose name is being changed may request a name change. Confirmation of any name
being changed will be sent to the owner of the policy.
How do you request a name change?
Complete the attached form listing both the old name and the new name and return to Symetra with
copies of the required supporting documents. You may fax the request to 1-866-532-1361 or mail
the request to the address below. If we receive original documents, they will be returned to you once
processing is complete.
Symetra Financial
PO Box 34690
Seattle, WA 98124-1690
Please call 1-800-796-3872 if you have any questions.
What is required for a name change?
If the Name Change is due to Marriage:
Please submit a photocopy of the certified or recorded Marriage Certificate OR,
Any 2 of the following:
A photocopy of your Drivers License, Social Security Card, or Passport.
If the Name Change is due to Divorce or Legal Name Change:
If the name change is due to Divorce, Adoption, Religion or a Legal Name change, a copy of the
certified copy of the legal document is required.
If the Name Change is due to inaccurate completion of the Application:
Please submit a copy of the birth certificate and legal documents to support any subsequent name
change.
Who needs to sign the form?
If the name change is for an individual:
Please have the person whose name is being changed sign the form.
If a corporation name is being changed: Please include:
A corporate resolution listing all of the individuals authorized to sign on behalf of the corporation
along with the notarized signature and title of a corporate officer. If the corporate resolution requires
more than 2 signatures these may be provided on separate paper and attached to this form when
returned.
OR
If a corporate resolution is not available, we will require the notarized signature of 2 corporate
officers along with their respective titles.

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Symetra is a registered service mark of Symetra Life Insurance Company.

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