Welcome John Smith
ABC Company

If you need to submit a change of address for more than one policy number, complete this form for each policy number requiring a change.

Legal name changes cannot be submitted using this form. To submit a name change, please contact your insurance consultant or local Employee Benefits Sales and Service Office.

* Denotes a required field. If no changes to our records are necessary for a required field, please enter either "No Change" or "N/C."

Policy and Contact Information
Policyholder Name *
   Policy Number *
Affiliate or Division Name (if applicable)
   Effective Date of Change *
Contact Person *
    New Contact?
Contact's E-mail Address
    New Contact E-mail?
Phone Number
- -
Fax Number
- -
Previous Address
 Check this box if the address remains the same.
Street Address *
Suite or PO Box
City *
 State *
ZIP Code *
-
New Address
 
Street Address *
Suite or PO Box
City *
 State *
ZIP Code *
-
Coverage in force with The Standard:
Life/AD&D  LTD  STD  Other 
Apply Changes To:
If contact applies to All of your Contacts, please check this box:
Otherwise, please select the contact to which this change applies.
  Contact Phone #
 Executive --
 Billing --
 Claims --
 Evidence --
 Tax --
 E-Services Administrator --
 ERISA Administrator (ERISA address changes require a street address.)
 ERISA Registered Agent