Death Beneficiary Input Form "*" indicates required fields Consumer Benefits of America-Howffers MembershipName of Insured Member* First Last Alternate Name First Last Gender* Female Male Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Beneficiary InformationBeneficiary Details % Name of Beneficiary Date of Birth Relationship Address Actions Edit Delete There are no Beneficiaries. Add Beneficiary Maximum number of beneficiaries reached. Percentage Allocated to BeneficiaryNumber BeneficiariesYou have not allocated 100% to your beneficiariesYou have allocated more than 100% to your beneficiariesI designate the person(s) on this form as my beneficiary(ies) to receive any payment from the association policy or policy number shown above. I fully understand that this designation of beneficiary(ies) applies to the full Death Benefit Amount that is in force.Insured Member's Full Name as Signature*Date* MM slash DD slash YYYY
