Life and Annuity Service Forms
You may use the following forms to make changes to your life insurance certificate or to report a claim. Simply click on the name of the form.
All forms should be completed and mailed to our office at the following address:
Assured Life Association
6025 S Quebec St., Suite 320
Centennial, Colorado 80111
Change of Name Form
This form should be used to record your change of name.
Change of Certificate Owner Form
This form should be used to record a change in or transfer the ownership of your certificate. All lines must be completed to effect the change. If there will not be a contingent owner, please indicate “none” on the form.
Change of Beneficiary Form
This form should be used to record your change of beneficiary. If you are listing a Trust as a beneficiary, we need to receive a complete copy of the Trust along with your change of beneficiary form. Please note the following are Community Property States: Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington, and Wisconsin. Community Property States require the spouse’s signature for changes on the certificate. If your spouse is no longer living, or if you are divorced, please indicate so on the form.
Authorization to Honor EFT Withdrawals
This form should be used to request automatic withdrawals from either your checking or savings account to pay the premiums on your certificate. If you have changed bank accounts, this form is required to make that change as well.
Contract Assignment Form
To assign the control of your life insurance certificate from the Owner to the Assignee please complete this form. By completing this form the current Owner of the certificate will relinquish all right, title, and interest in the certificate of insurance. The assignee’s rights including the ability to change beneficiaries, surrender, borrow upon or further assign the contract, as allowed by the certificate itself.
Death Claim Forms & Instructions
These forms should be used to make a claim for the death benefit of a certificate.
Direct Deposit Request Form
This form should be used if you wish to have a withdrawal automatically deposited to your bank account.
