Beneficiary Change to a Trust

---

The Savings Bank Life Insurance Company of Massachusetts Beneficiary Change Form - Trust Beneficiary Designation Policy Number(s): Name of Insured: Name of Policyholder(s): (if other than insured)

In lieu of payment as now provided, I hereby request that the net proceeds payable under each of the above policies in the event of death of the Insured be paid as follows: Name(s) of Trustee(s)

Address

Relationship to the Insured

Name(s) of Trustee(s)

Address

Relationship to the Insured

Name(s) of Trustee(s)

Address

Relationship to the Insured

as Trustee(s), or such Trustee(s) successor or successors, under the: ____________________________________________ ________________________________ Indenture of Trust dated: _____________________________________, without responsibility on the part of The Savings Bank Life Insurance Company of Massachusetts as to the application of the said proceeds by such Trustee(s). If the said Indenture of Trust is then terminated, the said proceeds shall be paid to the Owner or the Estate of the Owner. I hereby request that SBLI waive any requirement that this change be endorsed on the policy. I agree that the change herein requested shall be assumed to become effective without such endorsement, and I further agree that acknowledgment of receipt of this form by SBLI shall be construed as a waiver of the requirement of any such endorsement without further acknowledgment or notice by it.

Policyowner Signature(s):

_______________________________________________ ________________ Date _______________________________________________ ________________ Date Trust Tax Identification Number (required): ____________________________________ SIGNATURE OF WITNESS: I hereby certify under the penalties of perjury that I am over 18 years of age, a disinterested party who will not benefit from this policy and have witnessed the signing of this form by the policyowner. X ___________________________________________________ Signature of Witness

_____________________________ Date

If the previous Beneficiary on this policy has been designated “without power of revocation”, that Beneficiary must sign below. X____________________________________________________ Irrevocable Beneficiary

_____________________________ Date

DO NOT MAIL POLICY When processed, an acknowledgment will be sent to you for your records KB-3

(03-05)