GROUP INSURANCE CERTIFICATE CHANGE FORM: 

This form is used when an employee’s name changes, if a beneficiary change is desired, or when the original 
certificate is lost. 

The Plan Administrator should fill in the Group Number, Division Number and Policyholder Name at the top of 
the form. All other information should be completed by the employee. 

Both the employee and the Plan Administrator should sign the bottom of the form. 

Attach the original completed form to the employee’s enrollment form; give a copy of the form to the employee 
for attachment to the Certificate of Insurance. 

It is not necessary to send a copy of this form to our Home Office. 


See Instructions on Reverse

GROUP INSURANCE CERTIFICATE CHANGE FORM 

BOSTON MUTUAL LIFE INSURANCE COMPANY • 120 ROYALL STREET • CANTON, MASSACHUSETTS 02021-9968 • (800) 669-2668 
GROUP NUMBER DIVISION NUMBER EMPLOYER (POLICYHOLDER) NAME 
EMPLOYEE NAME (LAST, FIRST, MIDDLE INITIAL) 
CERTIFICATE # 


UNDER THE TERMS OF THE ABOVE POLICY(IES) I HEREBY REQUEST BOSTON MUTUAL LIFE INSURANCE COMPANY TO: 

. 
CHANGE OF BENEFICIARY 
Primary Beneficiary 
Relationship Date of Birth Address of Beneficiary 

Contingent Beneficiary (ies) 

ISSUE DUPLICATE CERTIFICATE (POLICY) because my original certificate (policy) has been lost or mislaid. I declare 
that such original certificate (policy) has not been pledged as security for any loan and that I do not know where such 
certificate (policy) is now. If such certificate (policy) is found I will surrender it to the Insurance Company immediately. 

To: 

. 
CHANGE OF NAME . 

I hereby agree that the copy of the signature appearing on the carbon copy of POLICYHOLDER’S ACKNOWLEDGEMENT OF CHANGE 
this form shall be accepted as my signature and I further agree to the conditions THE AUTHORIZED CHANGE(S) SET FORTH IN THE FOREGOING 
appearing on the reverse side hereof. INSTRUMENT ARE HEREBY ACKNOWLEDGED. 

Insured’s Signature Administrator’s Authorized Signature Administrator’s Copy 
Attach to 
Enrollment Card 

Date 
Date 

G-501 
221-048 6/04 

THE CHANGES REQUESTED ON THE FACE HEREOF SHALL BE OF NO EFFECT UNLESS INSURANCE IS IN FORCE ON 
THE LIFE OF THE “INSURED” UNDER THE DESCRIBED POLICY(IES) ON THE DATE OF ACKNOWLEDGEMENT. THE 
SUBMISSION ON THIS FORM AND THE ACKNOWLEDGEMENT THEREOF BY BOSTON MUTUAL LIFE INSURANCE COMPANY 
SHALL NOT BE CONSIDERED AN ADMISSION THAT ANY INSURANCE IS IN FORCE ON THE LIFE OF SAID “INSURED” 
UNDER SAID POLICY(IES). 

INSTRUCTIONS 
PHRASEOLOGY FOR NOMINATION OF BENEFICIARY 


TYPE OF BENEFICIARY 
PHRASEOLOGY 

1. ONE BENEFICIARY 
JANE DOE, WIFE 
2. 
TWO BENEFICIARIES JOHN DOE, FATHER AND MARY DOE, 
MOTHER, EQUALLY, OR THE SURVIVOR. 
3. 
THREE OR MORE BENEFICIARIES JANE J. DOE, WIFE, JOHN DOE FATHER, 
AND MARY DOE, MOTHER, EQUALLY, OR 
TO THE SURVIVORS, OR THE SURVIVOR. 
4. 
ONE BENEFICIARY AND ONE JANE J. DOE, WIFE, IF LIVING; OTHERWISE 
CONTINGENT BENEFICIARY ROBERT DOE, SON. 
5. ONE BENEFICIARY AND TWO 
JANE J. DOE, WIFE, IF LIVING; OTHERWISE 
CONTINGENT BENEFICIARIES 
ROBERT DOE, SON, AND ROBERTA DOE, 
DAUGHTER, EQUALLY, OR THE SURVIVOR. 

6. TWO BENEFICIARIES AND ONE 
JOHN DOE, FATHER, AND MARY DOE, 
CONTINGENT BENEFICIARY 
MOTHER, EQUALLY, OR THE SURVIVOR; 
OTHERWISE JANE J. DOE, WIFE.