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Beneficiary Change Request Form

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This form is used to establish and change the beneficiary designation of a life insurance policy or annuity contract.

Beneficiary Change Request Form

Before completing this form, please know:

  • By completing, signing, and submitting this form you are revoking and changing any and all previous beneficiary designations.
  • Insurance regulations require insurance companies to request supplemental beneficiary information. Please complete all information requested in Section 3 of this form.
  • The change requested will be effective from the signature date.


Using a blue or black ink pen

Submit in 1 of 3 Ways

Email: [email protected]

Fax: 1 (800) 946-1295

or Mail:
Pacific Guardian Life
Attn: Client Relations Department
1440 Kapiolani Blvd.,
Suite 1700
Honolulu, HI 96814