Beneficiary Change Form for Active Members Beneficiary Change Form Member's Name(Required) First Last Address(Required) Street Address City State / Province / Region ZIP / Postal Code Phone(Required)Email(Required) Death Benefit Beneficiary(Required) First Last Beneficiary Address(Required) Street Address City State / Province / Region ZIP / Postal Code Phone(Required)Email(Required) Relationship(Required)Contingent Beneficiary(s)(Required)Member's Signature(Required)Date(Required) MM slash DD slash YYYY Membership Number:(Required)Lodge Number(Required)
